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The need for stronger implementation of quarantine laws: how adopting China's strategy to fight SARS can help the United States effectively utilize quarantine powers in the fight against Ebola.


On September 19, 2014, Thomas Eric Duncan ("Duncan") left Monrovia, Liberia and arrived in Dallas, Texas the following day. (1) Eleven days later, he would become the first person to be diagnosed with a travel-associated case of Ebola in the United States. (2) Ebola is a deadly and infectious virus native to Africa that causes fever, muscle pain, vomiting, diarrhea, and bruising or hemorrhaging. (3) Usually, patients who die from Ebola due so from multiple organ failure and shock, which occurs primarily from blood vessel leakage in various parts of the body. (4) The recent Ebola outbreak ravaging Liberia and much of West Africa has been the most severe and deadly since its initial discovery in 1976, with a mortality rate of about seventy percent. (5) The disease spreads from person to person through direct contact with the blood or fluid secretions of symptomatic victims. (5) Carriers of the highly infectious virus can be asymptomatic. (6) Although Duncan was asymptomatic until September 24, 2014, health officials kept watch on the one hundred people whom Duncan and his family had been in contact with since his arrival to the United States. (7) Four of Duncan's close family members were ordered by Texas and Dallas County health officials to stay at home and to avoid visitors, in order to prevent the possible spread of the disease. (8) Without much delay, a second man was isolated and tested in a Washington, D.C. hospital for a possible Ebola infection separate from the Dallas, Texas incident. (9)

At least five confirmed people arrived from Africa with the Ebola virus, raising the issue of whether United States healthcare laws should be more stringent with respect to persons coming from areas of known infectious disease. (10) Devastating social and economic consequences from an Ebola outbreak could result in any city or town in the United States. (11) Based on the risk of exposure alone, Dallas County Health and Human Services kept five children at home to undergo precautionary monitoring due to possible exposure to the virus. (12)

A review of the laws governing entry of foreign nationals with communicable diseases to the United States may prove useful in order to understand how to institute more effective precautions against potential outbreaks. (13) Comparing the United States' laws of admissibility for those carrying infectious diseases with those of China's presents a striking contrast. (14) China has one-fifth of the world's population and one-seventh of the disease burden. (15) The country has undergone two separate outbreaks in just over ten years, the most extreme of which was the outbreak of the Severe Acute Respiratory Syndrome ("SARS") from 2002-2003. (16) A few years later, an H7N9, or Avian Flu, outbreak began and continues to affect China. (17) Chinese health officials know well the consequences of diseases and outbreaks, leaving no surprise that China's government exercises tight controls on foreign travelers. (18) Part I of this note describes a brief history of the development of quarantine laws in the United States and China, the United States legal quarantine scheme and the constitutional issues at stake, as well as China's approach to quarantine. (19) Part II describes the history surrounding the Ebola epidemic and contrasts it to the SARS outbreak China faced in 2003. Part II also discusses the strategies Chinese health officials implemented to prevent the epidemic from manifesting on a global scale. (20) Part III analyzes the strategies China implemented and offers suggestions for how the United States may implement similar strategies in the fight against Ebola. (21) This note ultimately concludes that the United States must utilize its quarantine laws effectively and in a timely manner, much like China has done in the past decade when China essentially eradicated SARS in a four-month period. (22)

I. History

The recent Ebola epidemic started in Guinea in December 2013. (23) As of February 2014, approximately 22,999 suspected cases and 9,268 deaths had been estimated. (24) The epidemic gained national attention with the diagnosis of Duncan as the first person in history diagnosed with Ebola in the United States. (25) Despite the six thousand mile distance between the United States and Liberia, the virus was transported from West Africa to the United States. (26)

A. Early Quarantines

The first formal practice of quarantine was implemented in Venice in the fourteenth century in response to the plague, or "The Black Death," which claimed the lives of over fourteen million people. (27) At the time, Venice required that ships stay anchored for forty days prior to landing. (28) The English word "quarantine" comes from the Latin phrase, "quaranta giorni," meaning "for forty." (29) The arbitrary quarantine length of forty days was eventually tailored to specific microorganism incubation periods after the advancement of medical microbiology in the late eighteenth century. (30)

B. History of Quarantine in the United States

Quarantine has a long-standing tradition in the United States. (31) Public protection against infectious disease fell under local and state jurisdiction as a state "police power." (32) In 1647, Boston was the first city to pass an ordinance requiring all arriving ships to remain at Boston Harbor's entrance for inspection of infectious disease agents. (33) In 1663, New York City passed a law forbidding people from entering the city until officials cleared those who came from areas known to have outbreaks of the infection. (34) By the 1700s, all major towns on the Eastern seaboard passed quarantine laws. (35) In 1701, Massachusetts enacted a statute requiring the isolation of all individuals infected with smallpox. (36) In 1866, New York potentially decreased cholera related deaths, when a ship containing infected people arrived from Liverpool, England; the passengers were subsequently quarantined. (37) By 1878, Congress passed federal quarantine legislation, the National Quarantine Act ("NQA"), in response to the continued yellow-fever epidemic, an Act that did not preempt states' rights. (38) The NQA authorized the Marine Hospital Service and the National Board of Health to control infectious diseases by granting these bodies quarantine power. (39) As microbiology developed further throughout the 1890s, the length of quarantine time was tailored to individual microbe life cycles. (40) In 1892, cholera reached the United States through the ports of Ellis Island. (41) Ellis Island was the nation's busiest immigrant processing station between the years 1892-1924.42 President Benjamin Harrison issued a mandate to the Surgeon General preventing any vessel carrying steerage-class immigrants from entering any port in the United States until that vessel had undergone a twenty-day quarantine. (43)

In 1944, with the codification of the Public Health Service Act, the federal government was given authority over quarantine powers. (44) In 1967, the Centers for Disease Control and Prevention ("CDC") accepted responsibility for quarantine decisions. (45) In the early 1990s, New York City detained over two hundred people who refused voluntary treatment of multidrug resistant tuberculosis ("TB"). (46) The CDC currently recommends that if TB cases are identified in hospitals, the cases should be reported promptly by contacting local health departments to begin initial legal quarantine practices if necessary. (47) In 2001, in response to the bioterrorism fears invoked by the September 11 attacks, the CDC released the Model State Emergency Health Powers Act, which provided states with a model statute, which they could adopt to enforce their quarantine rights in the event of an infectious bioterrorism attack. (48) In 2003, in response to the Severe Acute Respiratory Syndrome ("SARS") epidemic, President George W. Bush added SARS to the list of quarantinable diseases, which also includes Ebola. (49)

C. United States Legal Quarantine Scheme

The Federal quarantine law provides some regulatory oversight and gives explicit authority to prevent the spread of any communicable disease. (50) Federal quarantine authority derives from the Commerce Clause of the United States Constitution. (51) Originally, the Surgeon General was granted this authority, however, with the passage of the Reorganization Plan No. 3 of 1966 ("RPN 3"), statutory power was transferred to the Secretary of Health and Human Services ("Secretary of HHS"). (52) Currently section 361 of the Public Health Service Act grants the Secretary of HHS the authority to enforce necessary regulations "to prevent the introduction, transmission, or spread of communicable diseases from foreign countries into the States or possessions, or from one State or possession into any other State or possession." (53) The Reorganization Plan No. 3 of 1966 transferred all statutory powers and functions of the Surgeon General to the Secretary of HHS; in 2000, the Secretary of HHS transferred authority under this provision to the Director of the CDC. (54) The Surgeon General, with approval from the Secretary, may also issue orders of detainment as long as detainment serves the purpose of preventing the "introduction, transmission, or spread" of communicable diseases. (55) The detainment authority is only applicable when an individual crosses state or national borders and is infected with a communicable disease. (56) In a case where local authorities' efforts are inadequate to control the communicable disease in a certain region or state, the director of the CDC "may take such measures to prevent such spread of the diseases as he/she deems reasonably necessary." (57) A person who has a communicable disease in the "communicable period" may not travel from state to state without a permit from the health officer of that state. (58) With such laws and regulations in place in the United States, Ebola managed to spread to two healthcare workers caring for Duncan. (59) Shortly after the Duncan incident arose, the World Health Organization ("WHO") estimated that by December 2014, there would be as many as 10,000 new cases of Ebola each week. (60)

D. Legal History of Quarantine and Constitutional Rights

Since 1905, the United States Supreme Court has upheld laws favoring public health over individual autonomy. (61) In 1905, the Supreme Court decided Jacobson v. Massachusetts, ultimately upholding a Cambridge, Massachusetts mandatory vaccination policy. (62) The principles expressed in the opinion align with the purpose of quarantine; that ones' rights to their personal autonomy are secondary to the public need in response to epidemiological threats. (63)

More recently in 1963, the Eastern District of New York decided U.S. ex rel Siegel v. Shinnick ("Shinnick"), where the court upheld the mandatory quarantine of an individual suspected of smallpox exposure. (64) Although the individual did not display any symptoms of the disease, the mere fact of arrival from a smallpox ridden area was enough for the Court to uphold the fourteen-day quarantine of the individual. (65) The Court's reasoning was that an individual is considered a "suspect" of having the disease where they have been directly exposed to the infection by a quarantinable disease and are capable of spreading that disease (this includes asymptomatic carriers). (66) For a historical example, Mary Mallon, or "Typhoid Mary," was the first asymptomatic carrier of the pathogen associated with typhoid fever. (67) She infected approximately fifty-one people during her lifetime, three of which were known to have died from the infection. (68) Typhoid fever is not the only example of a disease where carriers can be asymptomatic; there are asymptomatic carriers of the Ebola virus as well. (69)

Although the purpose of quarantine is to protect the general public from those who are suspected of containing a highly contagious disease, courts will not broaden their scope. (70) For example, in Unites States v Comstock, the Supreme Court upheld detention of mentally ill, sexually dangerous prisoners who had served their prison sentence. (71) This upholding of a seemingly illegal detention was not due to an expansion of enumerated federal powers but rather it was "necessary and proper" to carry out the criminal laws enacted under Congress's enumerated powers. (72)

Regardless of the approach courts take to establish a quarantine or quarantine-like measure, the result is designed to ensure public safety. (73) Quarantine must be conducted in alliance with substantive and procedural due process, and must only impose reasonable and minimal restrictions on individual liberties. (74) There must be a compelling state interest in quarantining an individual, such a public health risk. (75) Ultimately there must be a balance between the public health and safety and the individual's civil rights. (76)

E. China's Approach to Quarantine

In 2003, China was able to contain the spread of SARS through a series of strict isolation methods coupled with an effective use of quarantine. (77) The Chinese State Council granted to the Chinese health administrative department officials the power to deem any region, whether in China or abroad, as "pestilence areas." (78) Under such power, once a region has been deemed pestilent, the State Council may take measures to prevent potentially infectious persons or materials from entry by giving orders to blockade the relevant sections of the border or designate primary air or sea-ports where the vessel can be searched and cleared for any communicable diseases. (79) Chinese health and quarantine officials have the right to prevent any persons suspected of having a communicable disease from exiting the country in order to prevent the potential spread of communicable diseases. (80) During the SARS epidemic, China implemented checkpoints at all public transportation systems including railways, coastal, airports, and bus stations, as well as frequent check stations on roads and highways to inspect for signs and symptoms of SARS. (81) China's prior experience with epidemics including Yellow Fever, cholera, and the plague serve as the historical basis for the strict quarantine laws of the Republic. (82) There are three subsections of China's quarantine laws devoted to the infectious diseases with which China's history has been plagued. (83) For example, Article 63 of the Frontier for Health and Quarantine Law covers quarantine procedures in the time of a plague epidemic. (84) These laws stem from China's history with the Plague in the century when China initiated policies that dealt with detaining Plague infected sailors who arrived at Chinese ports. (85) Quarantine in China may still have negative connotations given the history of equating the quarantine of the sick with criminals. (86) Yet in contrast to the United States, China does not regard individual rights as pressing an issue when national health is at stake. (87)

II. Facts

A. Recent United States Ebola Responses

Upon the recent outbreak of Ebola, the first measure taken to relieve public worry was limiting the number of airports where planes from Ebola-stricken countries could land. (88) These airports included: John F. Kennedy International in New York, O'Hare International in Chicago, Hartsfield-Jackson Atlanta International, Washington Dulles International near Washington, D.C., and Newark Liberty International in Newark, New Jersey. (89) On October 21, 2014, New York and New Jersey set up new quarantine measures, which went beyond what federal authorities had established. (90) These states initially issued requirements that travelers who come from areas at high risk of Ebola exposure go through mandatory twenty-one day quarantine at a government-run facility. (91)

Kaci Hickox ("Hickox"), a United States nurse volunteering in West Africa, arrived in the United States from Sierra Leone in October 2014. (92) Shortly after returning to the United States, she was placed under a mandatory quarantine in New Jersey despite exhibiting no symptoms of illness. (93) Hickox gained media attention when she opposed the quarantine on Fourteenth Amendment grounds. (94) After winning her case before a Maine judge, Nurse Hickox was allowed to self-monitor for the duration of the twenty-one day incubation period of the virus. (95) The Maine judge noted in his opinion "people are acting out of fear and ... this fear is not entirely rational." (96)

The constitutionality of mandatory quarantine became a topic of concern after the involuntary detention of Nurse Hickox. (97) After she prevailed in her legal battle against the State, New York governor Andrew Cuomo, but not Governor Chris Christie of New Jersey, added some flexibility to the quarantine mandate. (98) New York's update allowed travelers arriving from designated "high-risk" areas, but who were not showing any symptoms of the disease, to undergo a voluntary quarantine at their own residences where healthcare workers would check in with them twice daily. (99) Both governors initially argued that voluntary quarantine was not sufficient. (100) Because states reserve the right to police their own citizens, the New York and New Jersey health departments and lawmakers were permitted to determine their own procedures for quarantine and hospitalization, not federal authorities. (101) The New York and New Jersey quarantines prompted Florida and Illinois to consider similar measures. (102) Despite the debate over the constitutionality of healthcare mandates over citizens, states continue to have the right to enforce such measures so long as the procedure has a "real and substantial relation to the protection of the public health and safety." (103)

Federal and state authorities reserve the right to implement or amend quarantine laws amid relevant epidemics. (104) For example, the United States in 1952 passed the Immigration and Nationality Act, preventing the entry of foreign visitors with "communicable diseases of public health significance." (105) In 2007, George W. Bush advocated for the removal of Human Immunodeficiency Virus ("HIV") from the list of communicable diseases covered by the Immigration and Nationality Act because the listing was no longer based on current scientific evidence. (106) Similarly in 2010, China implemented legislation to allow the travel of HIV positive visitors. (107) HIV and Ebola are distinguishable conditions based on the risk of spreading to the general public. (108) HIV is spread via non-casual contact, such as by engaging in unprotected sex, while Ebola is contagious in a more casual contact capacity, such as by some skin-to-skin contact. (109) Ebola can be more easily compared to SARS because the two viruses are similar in their degree of transmission. (110) Both isolation and quarantine can be done on a voluntary basis, however, federal and state governments have the authority to impose mandatory quarantine and isolation for the public benefit. (111)

B. China's Ability to Minimize the SARS Epidemic

With globalization and the relative ease of international travel, any infectious disease outbreak can quickly threaten all countries. (112) China's experience in the control of the spread of SARS serves as a case study. (113) SARS, a highly virulent infectious disease caused by a corona virus, spreads quickly and easily. (114) In 2003, five probable SARS patients in Singapore were linked to events that resulted in the infection of at least ten healthcare workers, which accounted for a total of 103 to 205 probable SARS cases. (115) The underlying reasons behind the highly infectious and globally threatening facets of SARS were the novelty of the disease and the lack of a rapid diagnostic test or vaccine. (116) These factors contributed to the need to use non-medical control tactics such as mandatory quarantines and examinations. (117) In 2003, China declared the SARS epidemic a national security issue, leading the Chinese Communist Party and State Council, who had unlimited power over the nation, to issue several orders including ordering mandatory "fever check stations" at every transport area. (118) China even initiated checkpoints at every major public venue, including hotels, schools, theaters, and hospitals. (119) Within days, the government was able to establish 1,100 bed quarantine hospitals, which contained sewer treatment systems, electrical and water supply, and isolation rooms with negative air pressure to prevent the spread of the virus to healthcare workers. (120) Within days China was able to implement "world class infectious disease hospitals" all over the country. (121)

C. Understanding the Extent of Quarantine Regulation Today

In the Unites States, states' quarantine powers are granted through the Tenth Amendment. (122) Federal quarantine power can be derived from the Commerce Clause. (123) The premise of modern day quarantine laws is to reduce the transmission of disease by "increasing the social distance between persons." (124) Quarantine is only effective when the rights of the quarantined are taken into consideration along with the scientific understanding of the epidemiology of the highly communicable virus or disease. (125) When the quarantine exceeds the incubation period for the pathogen or virus in question, it is no longer necessary. (126) For Ebola, incubation is considered to be twenty-one days. (127) Although there are claims that patients are not contagious before they show symptoms such as fever, diarrhea and vomiting, whether the disease can be spread by other means, such as through sexual transmission before symptoms develop has not been proven conclusively. (128)

In the case of Thomas Eric Duncan, Duncan arrived at Texas Presbyterian Hospital as soon as his symptoms started to develop. (129) He was sent home without a diagnosis; when he later returned to the hospital because of persisting symptoms, he waited in a crowded emergency room. (130) Although Ebola is not airborne, it is easily transmittable through bodily fluids, expressed via sneezing, sweating, coughing, vomiting, and bleeding. (131) Soon after Duncan's death from Ebola, two of the nurses caring for him were subsequently diagnosed with the virus after contact with Duncan without purportedly wearing their personal protective gear correctly. (132) One of the nurses subsequently boarded a plane while having a slight fever. (133)

Quarantine slows the progression of highly contagious viruses and other infective organisms, allowing more time to develop vaccines, antibiotics, and to prepare isolation facilities. (134) The recent 2014 Ebola epidemic affected only a small number of countries, mainly in West Africa, which experienced highly active outbreak of the virus, including Liberia, Sierra Leone, Guinea, and Nigeria. (135) The United States government maintains the power to deny anyone from these regions from entering

the United States under the 1952 Immigration and Nationality Act. (136)

III. Analysis: Aligning the United States Quarantine Response with that of China's

A. Effectiveness of Quarantine Laws: A Look at United States History

If the United States had not employed such strict quarantine measures in 1647 when Boston was the first city on the eastern seaboard to recognize a formal quarantine ordinance, highly infectious diseases would have plundered through the population, annihilating many inhabitants. (137) The goal of quarantine is to eradicate disease outbreak by separating those who have been in contact with the disease or virus from those who have not. (138)

The term "quarantine" has been subjected to negative connotation in recent history. (139) Historical examples such as the events that took place on Ellis Island and the forever-infamous Typhoid Mary haunt the public conscience. (140) It is important to ascertain whether, historically, quarantines measures were effective at significantly preventing the spread of diseases, and if so, utilizing those same measures moving forward in the future. (141) A purpose of Ellis Island was to prevent immigrants carrying infectious diseases from bringing those contagions into the United States. (142) With the detainment of millions of people, ultimately a greater public good was accomplished as nine out of every ten individuals who were put into hospital quarantine units ultimately recovered and were deemed healthy enough to enter the United States. (143) From 1892 to 1954, nearly twelve million immigrants were processed at Ellis Island. (144) At a time when extremely infectious debilitating diseases were rampant given the lack of effective vaccines, antibiotics or personal protection equipment, quarantine was the only method effective enough to stop a population from becoming over-ridden with disease. (145) The manner in which the immigrants were processed at Ellis Island, although humiliating or terrifying for most, was relatively quick. (146) Each immigrant would receive a thirty-second medical examination that often involved new technology and testing methods, such as x-rays. (147) The quarantine methods employed were so effective that only two percent of immigrants were deemed too sick to gain entry to the United States, and were turned away. (148) However, a fraction of the immigrants were unnecessarily institutionalized for psychiatric care based on language and cultural barriers, often resulting in a loss of individual rights. (149) Quarantine stations were often unsanitary and non-sterile, resulting in a spread of disease by forcing those who were sick to be in contact with those who were healthy. (150) Often the targets of such quarantines were the lower classes, particularly immigrants. (151)

B. Quarantine and Constitutional Rights

State and federal governments are not given an absolute right to resort to the use of their quarantine powers, as there are limitations in place. (152) Such limitations require that the quarantine must be "the least restrictive means necessary to prevent the spread of a dangerous contagious or infectious disease." (153) This "least restrictive means approach" is vague and essentially raises the issue of what other methods might exist to contain the suspected virus, aside from quarantining individuals suspected of Ebola exposure. (154) If the individual is not quarantined and rides a crowded subway, such as in New York City as Dr. Craig Spencer did, the possibility arises that the virus will spread via a cough, sneeze, or perspiration through casual contact. (155) What could result is the beginning of a large epidemic in the United States, one that could result in not just the loss of civil liberties of one, two or ten individuals, but the complete quarantine of towns or even states depending on the scale of the spread. (156)

United States legal history provides ample evidence indicating that public safety is a priority, even if some individuals might lose some of their individual rights. (157) The Supreme Court ruled in Jacobson that: "[t]he liberty secured by the Constitution of the United States to every person within its jurisdiction does not import an absolute right in each person to be, at all times and in all circumstances, wholly freed from restraint." (158) The Jacobson Court added that "[t]here are manifold restraints to which every person is necessarily subject for the common good." (159) Yet in October 2014, Nurse Kaci Hickox argued for her freedom when she was subject to a mandatory quarantine in New Jersey, despite exhibiting no symptoms of the disease. (160) Like Hickox, the plaintiff in Shinnick had traveled abroad to a disease-ridden country, where smallpox was rampant. (161) Like Hickox, Shinnick exhibited no symptoms of the disease when she was forced into a mandatory quarantine. (162) Yet the court in Shinnick upheld the mandatory quarantine whereas Hickox was relieved of her mandatory quarantine from the Maine judge who deemed the quarantine to be unreasonable. (163) As evidenced by Jacobson, Shinnick and Comstock, United States' courts have historically been inclined to favor the loss of certain individual rights in the wake of rampant debilitating infectious diseases. (164) As long as quarantine lengths are appropriated based on epidemiology of the disease, then such quarantines are the least restrictive means of preventing the spread of disease.165 Plaintiff Shinnick was subject to a fourteen-day quarantine since that was the known incubation period of the smallpox virus at the time. (166) Similarly, Nurse Hickox was initially subjected to a twenty-one day quarantine because of the known incubation period for the Ebola virus. (167) The fact remains that asymptomatic carriers of the Ebola virus have been identified through scientific studies, so the presentation of an individual arriving from an Ebola-stricken region free of symptoms is not enough reason to put the public health at risk. (168) The implications of Nurse Hickox's recent victory over quarantine may be that state governments steer away from the use of quarantine, even given historical successes. (169)

C. United Stated Should Follow China's Model of Quarantine

China, like the United States, has a rich history of effective uses of quarantine to prevent the spread of disease, and in some cases, to eradicate disease. (170) In order to stop a highly infectious disease like Ebola, the United States should revert to earlier case law and historical examples of how other countries, faced with similar epidemics, were able to achieve the third, and arguably most important goal of the quarantine law which is to "eliminate the vector" and eradicate the disease on a local scale. (171)

On May 19, 2004, the WHO declared that SARS has been eradicated in China. (172) SARS had earlier been projected to be the first outbreak of the twenty-first century to result in an epic and uncontrolled public health disaster. (173) Never before had the modern world seen such an epidemic. (174) China, seemingly overnight, built hospitals specifically for quarantined individuals and installed fever checkpoint stations at every public transport system in response to the crisis. (175) Within months, China was able to eradicate SARS. (176)

There are similarities between the statutory authority governing quarantine regulations in China and in the United States. (177) The first Article of the China Frontier Health Law states the purpose of quarantine measures is to "to protect human health." (178) Similarly, the United States quarantine laws seek to "prevent the introduction, transmission, or spread of communicable diseases." (179) Modern science no longer makes establishing arbitrary quarantine lengths of earlier centuries an option. (180) Even one day of unnecessary human confinement is a violation of an individual's right to privacy and could be deemed unconstitutional. (181) When administering quarantine, the state or federal government must be sure to employ the least restrictive means that are both reasonable and necessary to ensure the public's health and safety. (182) Today, quarantine length is governed by facts and scientifically proven data obtained through federally funded organizations such as the CDC or WHO. (183) The issue is not in quarantining people, but in setting unreasonable quarantine periods. (184)

Under the Chinese SARS quarantine act, individuals remained at quarantine facilities and were actively monitored for five to seven days, the length of incubation for corona-virus. (185) Similarly in the United States, quarantine lengths for those who arrive from virus-ridden areas must be twenty-one days, the known incubation period for the Ebola virus. (186) Quarantining an individual at high risk for an Ebola infection for twenty-one days serves a dual purpose: for the individual, who receives daily health care evaluation which can protect their own health and secondly, as for the general public, who may be saved from exposure to the virus. (187) If the individual is contained for any period above twenty-one days without showing any symptoms, holding the individual is no longer quarantine but imprisonment. (188) The difference between quarantine and imprisonment is arguably whether or not the "least restrictive approach" is utilized during the quarantine. (189) Contributing factors that should be utilized when deciding whether quarantine is necessary include proof by scientific data and advice from experts in the field. (190) As long as legislative measures are condoned by scientific and medical experts, and as long as the political and scientific community work in harmony to limit the degree of freedom taken away from suspected individuals while maximizing the benefit and safety to the public at large, then the quarantine measures become an invaluable public resource. (191) China has proven this through data showing a four-month eradication of a potentially globally devastating epidemic. (192) China, which has been criticized for tough actions against individual liberties within its borders, utilized quarantine lengths based upon the incubation period of the SARS virus, in addition to setting up fever checkpoints at strategic places and hundreds of medical units to treat those who were sick and prevent them from spreading the illness. (193) If China had not utilized these methods, or if Chinese courts had deemed these methods too unreasonable, like the Maine court recently held in Hickox's case, then it is doubtful that a country with a population of 1.3 billion people could have prevented SARS from escalating out of control. (194)

The United States should be more willing to take similar actions as China's during the SARS outbreak, given that more Ebola cases could arise in the United States if such action is not taken. (195) This is not to say that the United States should follow China's every strategy, as China's quarantine methods could have been optimized such that the number of individuals quarantined could have been reduced by sixty six percent. (196) In order to reduce the number of those quarantined, Chinese authorities should have focused on individuals who had been in contact with actively ill SARS patients instead of solely focusing their efforts on the general public, which constituted nearly 1.3 billion individuals. (197)

At the outset of SARS, China was faced with a disease that was unknown and its epidemiology not understood in the scientific community, much like the United States faced with the 2014 Ebola outbreak. (198) China apdy recognized that although medical information was scarce and not widely understood, what was known was the speed at which the virus spread and its fatality, therefore China correctly chose to react immediately, taking measures to prevent SARS' spread and to contain the virus. (199) China contained the SARS virus and potentially saved millions of lives. (200) The United States should learn from China that when facing virulent, easily transmittable disease epidemics, a country must immediately focus efforts on containing the disease and preventing further spread. (201)

The recent measures taken in Nigeria, a country with a population of twenty-one million people further exemplify the valuable potential of effective utilization of quarantine laws. (202) On October 20, 2014, WHO declared Nigeria free of Ebola transmission after nearly four months battling the virus. (203) The vims was stopped due to the immediate construction of isolation wards, similar to China's immediate construction of SARS specific quarantine hospitals and monitoring suspected infected individuals for the twenty-one day Ebola incubation period. (204) WHO acknowledged the Chinese quarantine "greatly diminished opportunities for further transmission" which accomplished the purpose of quarantine. (205) The United States should learn from countries such as Nigeria and China and effectively utilize their quarantine laws to respond quickly to disease outbreaks to stop the contagious agent before it becomes an epidemic. (206)

IV. Conclusion

Although perceived as unattractive and as a last resort to disease outbreak, quarantine exists as perhaps the most effective way to protect a public facing a grave and fatal infectious disease outbreak. Historically, quarantine has proven to be an efficient and effective means to prevent the spread of infectious diseases, albeit controversial. The epidemiological information regarding the spread of Ebola has not been substantially studied as there has never been a large scale outbreak capable of spreading with such ease as the recent outbreak, given the speed and frequency of international travel in today's modern world. In order to determine the best course of action to take in response to such a potentially catastrophic outbreak, the scientific community must work with the legislative community to provide substantiated, data-based input to help legislatures determine an appropriate response. Since the United States currently lacks a consensus among the scientific community with regards to many aspects of Ebola, and a cure or vaccine is currently unavailable, every precaution to control the virus and prevent the spread of the disease, including quarantine, should be considered and guidance should be drawn from the experience of China's SARS response.

(1) Tom Winter, M.L. Flynn & Robert Dembo, Timeline: How Ebola Made Its Way to the U.S., NBC NEWS, Oct. 2, 2014, 2:17 PM, available at ebola-made-its-way-u-s-n216831. An important concern with Duncan's diagnosis of Ebola was not only for his safety, but the concern for the one hundred people he came into contact with after his exposure. Id. The need to stop the disease become evident when considering the ease of a highly virulent and contagious virus to spread within a community. Id.

(2) Id. See also Cases of Ebola Diagnosed in the United States, CTRS. FOR DISEASE. CONTROL & PREVENTION, ed-case.html (last updated Dec. 16, 2014) (describing timeline of healthcare worker's disease progression upon returning from treating Ebola victims overseas).

(3) Signs and Symptoms, CTRS. FOR DISEASE CONTROL & PREVENTION, ebola/symptoms/index.html (last updated Nov. 2, 2014) (describing signs and symptoms of Ebola during twenty one day incubation period post exposure).

(4) Amanda L. Chan, What Actually Happens When a Person Is Infected With the Ebola Virus, HUFFINGTON Post, (Aug. 2, 2014, 9:24 AM), available at 08/02/ebola-symptoms-infection-virus_n_5639456.html. The Zaire strain of the Ebola virus was the strain involved in the 2014 outbreak of Ebola. Id. Although the fatality rate of the strain is said to be 90%, doctors speculate that it is high because of poor healthcare in the regions most affected; however, the mortality rate is 60% when supportive care is received. Id. The infection route of Ebola is not known to infect humans through the air, but through exposure and contact of the infected peoples' bodily fluids such as sweat and saliva, which can survive outside the host for one to two days at room temperature. Id. Contamination also occurs through contact with infected animals and items contaminated with the virus. Id. Once the virus makes its way into the body's cells, it replicates itself and produces a protein called the ebolavirus glycoprotein that attaches to the cells on the inside of blood vessels causing them to become permeable and leak blood. Id.

(5) See Transmission, NAT'L INST. OF ALLERGY AND INFECTIOUS DISEASES, topics/ebola-Marburg/understanding/Pages/transmission.aspx (last visited Apr. 21, 2015) (describing transmission route for Ebola virus); Travel and Transport Risk Assessment: Interim Guidance For Public Health Authorities and the Transport Sector, WORLD HEALTH ORG. (last updated Sept. 10, 2014), WHO_EVD_Guidance_TravelTransportRisk_14.1_eng.pdf?ua=1&ua=1&ua=:1 (further describing transmission route and risks involved with travel in countries associated with Ebola outbreaks).

(6) E.M. Leroy, et al., Human Asymptomatic Ebola Injection and Strong Inflammatory Response, 355 LANCET 2210, (2000), available at (describing scientific study done in Gabon). Two outbreaks of fulminating haemorrhagic fever occurred in northern Gabon in 1996 with a 70% fatality rate. Id. Blood was analyzed from twenty-four individuals who had close contact with infected symptomatic patients, but they themselves were seemingly uninfected. Id. The study found that of those twenty-four individuals, eleven were asymptomatic carriers of the Ebola virus. Id.

(7) See supra note 1 and accompanying text (describing Ebola's progression from time of exposure to death). See also Todd L. Davis, About 100 People Might Have Had Contact With Dallas Ebola Patient or Family: Officials, NBC DFW (Oct. 2, 2014, 3:55 PM), available at Duncan's nephew claimed his uncle was not treated properly the first time he appeared at the emergency room displaying symptoms of Ebola. Id. Marjorie Owens, Miles: 5 DISD Students Possibly Exposed To Ebola, ABC WFAA (Oct. 1, 2014, 7:07 PM), available at Having told the nurse at the emergency room that he had just arrived from West Africa, some argued that the nurse could be expected to have done some diligence and examined him further instead of sending him home, where he then came in contact with five school-aged children. Id. Those children's health was monitored at their homes for the next twenty-one days to ensure both their safety and to prevent the possibility that they would spread the virus among their classmates. Id.

(8) Texas Orders Family of Ebola Patient to Stay Home, TEXAS Dep't OF STATE HEALTH SERVS. (Oct. 2, 2014), (describing quarantine-like process Duncan's family had to endure after Duncan was announced dead). Although not explicitly called a quarantine order, the Texas State Department ordered Duncan's family members to remain in their home until the twenty-one day incubation period terminated. Id. '"We have tried and true protocols to protect the public and stop the spread of this disease,' said Texas Health Commissioner Dr. David Lakey. 'This order gives us the ability to monitor the situation in the most meticulous way.'" Id. See also TEXAS HEALTH & SAFETY CODE ANN. [section] 81.083(b) (LexisNexis 2014).
   If the department or a health authority has reasonable cause to
   believe that an individual is ill with, has been exposed to, or is
   the carrier of a communicable disease, the department or health
   authority may order the individual, or the individual's parent,
   legal guardian, or managing conservator if the individual is a
   minor, to implement control measures that are reasonable and
   necessary to prevent the introduction, transmission, and spread of
   the disease in this state.

Id. This gives the state authority to quarantine people in cases where the health department has reasonable cause to believe that a group or individual has been exposed to a communicable disease in their homes until they are deemed non-contagious or disease free. Id. The code applies criminal penalties to those who knowingly refuse to perform or allow the performance of the control measured in the order. Id. The Code permits for law enforcement to use reasonable force to enforce this code provision. Id.

(9) See Patient at D.C. 's Howard University Hospital Does Not Have Ebola, NBC WASH. (Oct. 8, 2014, 3:07 PM), available at Howard-University-Hospital-278025181 .html (describing similarity between symptoms of Ebola and Malaria). A patient was taken to Howard University Hospital in Washington, D.C. for a suspected Ebola infection and was isolated from the general population. Id. After subsequent testing it was determined that the individual did not in fact have an Ebola infection, but rather was suffering symptoms of malaria. Id. The White House made a statement addressing the work of the hospital staff as a "precaution." Id.

(10) See Should the U.S. Implement Travel Restrictions on Countries Impacted by Ebola? U.S. NEWS, (last visited Apr. 21, 2015) (debating U.S. restrictions on foreign travels in light of recent Ebola cases); Jacque Wilson, Who are the American Ebola Patients? CNN (Oct. 6, 2014, 12:57 PM), (describing total known Ebola cases in United States). See generally 2014 Ebola Outbreak in West Africa--Case Counts, Ctrs. For Disease Control & Prevention, outbreaks/2014-west-africa/case-counts.html (last visited Apr. 21, 2015).

(11) See How Fear of Ebola Could Impact the US Economy, ABC NEWS (Oct. 3, 2014, 8:31 AM), (discussing how fear of Ebola may influence U.S. travel, tourism, and productivity). See also Assessing the Socio-Economic Impacts of Ebola Virus Disease in Guinea, Liberia, and Sierra Leone, The Road to Recovery, United Nations Development Programme (2014), dam/rba/docs/Reports/EVD%20Synthesis%20Report%2023Dec2014.pdf (describing socioeconomic impact of Ebola in several African countries).

(12) Marjorie Owens, Miles: 5 DISD Students Possibly Exposed To Ebola, ABC WFAA (Oct. 1, 2014, 7:07 PM), available at cases/16524303/. During Duncan's two visits to the emergency room, the treatment he underwent exposed five other school children to his illness. Id.

(13) See Public Health Interstate Quarantine 42 C.F.R. [section] 70.5 (2015) (providing rules for "certain communicable diseases"). The regulation provides:

The following provisions are applicable with respect to any person who is in the communicable period of cholera, plague, smallpox, typhus or yellow fever, or who, having been exposed to any such disease, is in the incubation period thereof: (a) Requirements relating to travelers. (1) No such person shall travel from one State or possession to another, or on a conveyance engaged in interstate traffic, without a written permit of the Surgeon General or his/her authorized representative.

(2) Application for a permit may be made directly to the Surgeon General or to his/her representative authorized to issue permits.

(3) Upon receipt of an application, the Surgeon General or his/her authorized representative shall, taking into consideration the risk of introduction, transmission, or spread of the disease from one State or possession to another, reject it, or issue a permit that may be conditioned upon compliance with such precautionary measures as he/she shall prescribe

(4) A person to whom a permit has been issued shall retain it in his/her possession throughout the course of his/her authorized travel and comply with all conditions prescribed therein, including presentation of the permit to
   the operators of conveyances as required by its terms, (b)
   Requirements relating to operation of conveyances. (1) The operator
   of any conveyance engaged in interstate traffic shall not
   knowingly: (i) Accept for transportation any person who fails to
   present a permit as required by paragraph (a) of this section; or
   (ii) Transport any person in violation of conditions prescribed in
   his/her permit. (2) Whenever a person subject to the provisions of
   this section is transported on a conveyance engaged in interstate
   traffic, the operator thereof shall take such measures to prevent
   the spread of the disease, including submission of the conveyance
   to inspection, disinfection and the like, as an officer of the
   Public Health Service designated by the Surgeon General for such
   purposes deems reasonably necessary and directs


(14) See Frontier Health and Quarantine Law of the People's Republic of China, CHINA.ORG, (last visited Apr. 21, 2015) (enlisting China's communicable disease quarantine laws).

(15) See China to Study Links Between Sustainable Development and Investment in Health, WORLD HEALTH ORGANIZATION (Dec. 18, 2002), (describing report linking health, poverty reduction and economic growth). The report argued that good health will automatically lead to positive economic growth. Id.

(16) Laurie Garrett, How to Shut Down a Country and Kill a Disease, FOREIGN POLICY (Oct. 23, 2014), _disease_sars_china_ebola (discussing SARS outbreak in China).

(17) See The Fight Against Bird Flu, NATURE (Apr. 24, 2014), available at 12850 (describing China's measures to report, treat, and prevent the epidemic of the H7N9 bird flu).

(18) See Frontier Health and Quarantine Law of the People's Republic of China, supra note 14, at ch. II, art. 7 (providing Article Seven's quarantine inspection law). The law provides:
   Persons and conveyances on entering the country shall be subject to
   quarantine inspection at designated places at the first frontier
   port of their arrival. Except for harbour pilots, no person shall
   be allowed to embark on or disembark from any means of transport
   and no articles such as baggage, goods or postal parcels shall be
   loaded or unloaded without the health and quarantine inspector's
   permission. Specific measures for the implementation of this Law
   shall be stipulated in detailed regulations.


(19) See infra Part I.

(20) See infra Part II.

(21) See infra Part III.

(22) See infra Part IV.

(23) See Ebola: Mapping the Outbreak, BBC NEWS Africa (Apr. 13, 2015), (last visited Apr. 22, 2015) (discussing major Ebola outbreak beginning March 2014, originating in West Africa in 1976). New England Journal of Medicine researchers traced the outbreak to a toddler who perished in southeast Guinea in December 2013. Id.

(24) See id. (describing Ebola related deaths by country throughout Africa). As of February 10, 2015, the World Health Organization ("WHO") estimated that total deaths in Liberia amount to 3,858 victims; total deaths in Sierra Leone amounted to 3,363 individuals. Id. In Guinea, the total deaths reported were 2,032 individuals. Id.

(25) See Lisa Maria Garza & Sharon Begley, Ebola Patient in Dallas Struggling to Survive Says CDC Head, REUTERS (Oct. 5, 2014, 7:41 PM), http://www.reuters.eom/article/2014/10/05/us-healthebola-usa-idUSKCN0HT0MZ20141005 (last visited Apr. 22, 2015) (describing Duncan's treatment process during his initial visit to the emergency room). Had Duncan been treated appropriately during the first emergency room visit, his life would likely have been saved and risk of public exposure would have been presumably minimal. Id.

(26) Id.

(27) See Science Museum, The Black Death and Early Public Health Measures, SCIENCE MUSEUM: Brought to Life, Exploring the History of Medicine, (last visited Apr. 22, 2015) (reviewing treatment methods from the 1400s to deal with plague). One means believed to thwart the plague was through religion. Id. Religion played an important role in people's health care because medicine was not well developed at that point in history, and there was little to no understanding of disease. Id. Most saw disease as a form of punishment from God. Id. Other responses to disease included drinking potions laced with mercury, arsenic, or ground unicorn horn. Id. The most effective method utilized to control disease was turning away incoming ships. Id. During the spread of the Black Plague in Italy in 1347, ports began turning away ships suspected of arriving from plague-infected areas. See The Black Death and Early Public Health Measures, supra. It was March 1347 when Venice became the first to formalize such protective measures against the plague by closing the city's waters to suspected vessels. Id. Additionally Venetians would subject travelers and legitimate ships to thirty days isolation, later extended to forty days, and given the term "quarantine." Id. Inland Italy took further measures. Id. In May 1348, the northern city of Pistoia introduced laws, which affected aspects of everyday life and restricted imports, exports, travel, market trading, and funerals. Id. These heavily-burdening laws had little effect, as 70% of the population perished because of the plague. Id. However, in Milan such extreme measures proved effective. See The Black Death and Early Public Health Measures, supra. In Milan, homes of families who were suspected of being plague-stricken were sealed up with the occupants inside. Id. In 1350, the Milanese authorities decreed that any future plague victim and whoever was to nurse them was to be sent to a pesthouse outside of the city walls. Id.

(28) Id.

(29) Id.

(30) See Peter Tyson, A Short History of Quarantine, PBS (Oct. 12, 2004), nova/body/short-history-of-quarantine.html (last visited Apr. 23, 2015) (describing history of quarantine laws). Quarantine laws date back to 549 A.D. when, in the wake of a bubonic plague epidemic, the Byzantine emperor Justinian enacted laws aimed at isolating visitors arriving from plague-infested regions. Id. In 583 A.D., the Council of Lyons restricted lepers from freely associating with healthy individuals. Id. Sixty years later, in the 600s, China established policies to detain plague-stricken sailors and foreign travelers who arrived in Chinese ports. Id. Decades later in the 1200s, Europe had 19,000 "leprosaria" or houses for leper patients, 2,000 of which were located in France. Id. A century later, European and Asian countries began enforcing quarantine by placing armed guards around quarantined areas where they could execute those who did not obey the quarantine. Id. In 1348, Venice established the first institutionalized system of quarantine. See Tyson, supra. In 1521, France's first maritime quarantine opened at Marseilles, where officials enacted laws forbidding anyone from entering the city without a preliminary medical examination. Id. In 1647, Boston became the first region in United States to enact an ordinance requiring all ships to pause at the harbor entrance or risk a $100 fine. Id. New York City followed in 1663 and by the mid-1700s every major city along the eastern seaboard of the United States passed quarantine laws to be enforced only when epidemics appeared imminent. Id. See also Ellis Island Oral Histories, NATIONAL PARK SERVICE, (last visited Apr. 23, 2015) (describing first hand experiences of those who went through medical examinations of Ellis Island); ELLIS ISLAND: Through America's Gateway, usonline/worldoc/ellisislandsite.htm (last visited Apr. 23, 2015) (discussing historical context of Ellis Island).

(31) Tyson, supra note 30 (describing initial history of quarantine law in the United States).

(32) See U.S. CONST, amend. X. "The powers not delegated to the United States by the Constitution, nor prohibited by it to the states, are reserved to the states respectively, or to the people." Id. See also Jacobson v. Massachusetts, 197 U.S. 11, 31 (1905) (upholding states' authority to enforce compulsory vaccination laws); JARED P. COLE, CONG. RESEARCH SERV., RL33201 Federal and State Quarantine and isolation Authority (2014), available at (covering federal authority and state authority of quarantine powers and potential legal limitations imposed); LAWRENCE O. GOSTIN, PUBLIC Health Law: Power, Duty, Restraint 424 (Univ. of Cal. Press 2nd ed. 2008) (describing early municipal ordinances for quarantine laws in Boston, Long Island, and New York).

(33) Tyson, supra note 30 (describing initial quarantine acts implemented in United States).

(34) Id.

(35) Id.

(36) Id.

(37) See id. (describing how New York implemented changes to reduce and prevent outbreak of Cholera). New York began implementing quarantines in 1663 during a smallpox epidemic. See id. In 1866 a ship called the "steamer Virginia" arrived in New York from Liverpool. Tyson, supra note 30. Thirty-five passengers died during the voyage from the disease. See id. It is most likely because of this quarantine that New York was able to limit the amount of deaths to a six hundred amidst this outbreak. See id.

(38) See Jerrold M. Michael, The National Board of Health: 1879-1883, PUB. HEALTH REP. 123, 126 (2011), available at 0123a.pdf. After discussing the need for a unified national health service at four Sanitary Conventions, the NQA was initiated. See id. at 124-26.

(39) See id. The Marine Hospital Service was a centralized organization of locally controlled hospitals based out of Washington, D.C. John Parascandola, Public Health History, Commissioned Officers Assn. of the USPHS Inc., available at (last visited Apr. 21, 2015). See also An Act to Prevent the Introduction of Contagious or Infectious Diseases into the United States, National Quarantine Act, ch. 66, 20 Stat. 37 (1878), available at downloads/20StatL37.pdf (describing which organizations had a right to quarantine infected individuals). Section 3 describes the powers granted to the Marine Hospital Service to enforce quarantine on infected individuals. See id. In 1979, Congress created the National Board of Health which was given quarantine power, including maritime quarantine. See Michael, supra note 38. In 1883, the act that created the National Board of Health expired and was not renewed by Congress, thus reverting the quarantine powers to the marine Hospital Service. See id. at 127.

(40) Tyson, supra note 30 (describing role of medical microbiology in tailoring quarantine time, making it disease specific).

(41) Felice Badan, Law in the Time of Cholera: Disease, State Power, and Quarantines Past and Future, 80 Temp. L. Rev. 53, 81 (2007).

(42) Ellis Island History & Culture, Nat'l PARK SERV., historyculture/index.htm (last visited Apr. 20, 2015) (describing functions of Ellis Island as an immigrant processing station from 1892-1924).

(43) Badan, supra note 40, at 82. The quarantine length of twenty days was chosen as a standard at this time, even though medical microbiology had significantly improved. See id. See also Eugine Tognotti, Lessons from the History of Quarantine, from Plague to Influenza A, 19 EMERGING Infectious Diseases 254 (2013).
   A turning point in the history of quarantine came after the
   pathogenic agents of the most feared epidemic diseases were
   identified between the nineteenth and twentieth centuries.
   International prophylaxis against cholera, plague, and yellow fever
   began to be considered separately. In light of the newer knowledge,
   a restructuring of the international regulations was approved in
   1903 by the 11th Sanitary Conference, at which the famed convention
   of 184 articles was signed.

Id. Even with the knowledge that germs cause diseases, the specific bacteria, pathology, incubation periods, and symptoms were still not known at the time. See id. See also Howard Markel, How the Ebola Quarantine Became a 'States' Bights' Issue, REUTERS (Oct. 30, 2014), (evaluating confusion that ensues in United States when epidemics arise). In the course of history in the United States, there have been longstanding debates over what powers are given to the federal government and which belong to the states. See id. In the summer of 1892, when cholera had devastated much of Eastern Europe, New York City, then the largest port in the United States receiving 75% of immigrants, began receiving its first cholera victims. See id. President Benjamin Harrison, who was in the middle of a re-election campaign, encouraged states to develop their own containment protocols which included quarantine of immigrants for as long as necessary until it became too expensive for the ship owners. See id. However, after being advised that this would lead to a lack of uniformity among states' quarantine procedures, on September 1 of that year, after consulting with his Surgeon General Walter Wyman, the President arranged for a mandatory twenty day quarantine for uniformity's sake. See id. Even though President Harrison lost the re-election campaign of 1893, his executive order resulted in the National Quarantine Act of 1878, giving the president the power to contain an epidemic crisis. See id. See also Stephen H. Waterman et al., A New Paradigm for Quarantine and Public Health Activities at Land Borders: Opportunities and Challenges, 124.2 Pub. HEALTH REP. 203-11 (2009) available at

(44) Quarantine and Isolation, History of Quarantine, CTRS. FOR DISEASE CONTROL & PREVENTION, (last updated July 31, 2014) (describing increased role of federal government in quarantine administration in late 19th Century); Quarantine and Isolation, CDC, (last visited Apr. 2, 2015) (explaining differences in quarantine and isolation).

(45) History of Quarantine, CTRS. FOR DISEASE CONTROL & PREVENTION, quarantine/historyquarantine.html (last updated July 31, 2014).

(46) See Richard Coker, From Chaos to Coercion: Detention and the Control of TUBERCULOSIS 141-42 (2000); Barrin H. Lerner, 'Tough 1 awe' lessons From a Deadly Epidemic, NY TIMES (June 27, 2006), available at See also CTRS. FOR DISEASE CONTROL & PREVENTION, Notes and Keports Nosocomial Transmission of Multidrug-Pesistant Tuberculosis Among HIV-Infected Persons--Florida and New York, 1988-1991, Morbidity and Mortality Weekly Rep. (Aug. 30, 1991), available at mmwr/preview/mmwrhtml/00015030.htm (describing transmission mode of multi-resistant TB, particularly among HIV-infected persons). The CDC assisted hospitals in implemented legal quarantine procedures in cases of suspected multidrug resistant tuberculosis. See id.

(47) CTRS. FOR DISEASE Control & PREVENTION, Controlling Tuberculosis in the United States Recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America, 54 Morbidity and Mortality Weekly Rep. No. RR-12 (Nov. 4, 2005), available at

(48) Larry O. Gostin, Model State Emergency Health Powers Act, CDC STACKS PUBLIC HEALTH PUBLICATIONS (Dec. 21, 2001), available at (aiming to aid state legislatures in the control and response to epidemics and bioterrorism). See also Model State Emergency Health Powers Act, AMERICAN CIVIL LIBERTIES UNION (Jan. 1, 2002), available at https: // (describing purpose of Act to increase state powers in response to public health emergencies).

(49) Exec. Order No. 13295, 68 Fed. Reg. 17255 (Apr. 4, 2003) (listing cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, viral hemorrhagic fevers, and SARS). See also Bush Order Allows SARS Quarantine, CNN (Apr. 4, 2003, 6:49 PM), 2003/HEALTH/04/04/sars.bush/.

(50) See 42 U.S.C. [section] 264 (2002). Subsection (a) of the regulation states, in pertinent part:
   The Surgeon General, with the approval of the Secretary, is
   authorized to make and enforce such regulations as in his judgment
   are necessary to prevent the introduction, transmission, or spread
   of communicable diseases from foreign countries into the States or
   possessions, or from one State or possession into any other State
   or possession. For purposes of carrying out and enforcing such
   regulations, the Surgeon General may provide for such inspection,
   fumigation, disinfection, sanitation, pest extermination,
   destruction of animals or articles found to be so infected or
   contaminated as to be sources of dangerous infection to human
   beings, and other measures, as in his judgment may be necessary.

42 U.S.C. [section] 264 (a). See also Specific Laws and Regulations Governing the Control of Communicable Diseases, CTRS. FOR DISEASE CONTROL & PREVENTION, specificlawsregulations.html (last visited Apr. 20, 2015) (discussing various federal laws, regulations and executive orders regarding quarantine and isolation).

(51) U.S. CONST, art. I, [section] 8, cl. 3. The Commerce Clause gives Congress the power "to regulate commerce with foreign nations, and among the several states, and with the Indian tribes." Id.

(52) See 42 U.S.C.A. [section] 202 (2006) (1966 Reorganization Plan No. 3); 5 U.S.C.A. [section] App. 1 Reorg. Plan 3 (1966), available at USCODE-2009-title5-app-reorganiz-other-dup79.htm (assigning authority to HHS Secretary). See also JARED P. COLE, CONG. RESEARCH SERV., RL33201, FEDERAL AND STATE QUARANTINE AND ISOLATION Authority (2014), available at RL33201.pdf (describing transfer of quarantine power to Secretary of Health and Human Services)

(53) 42 U.S.C. [section] 264 (a). See also JARED P. COLE, CONG. RESEARCH SERV., RL33201, FEDERAL AND State Quarantine and Isolation Authority 1, 1-2 (2014), available at In 2000, the Secretary transferred certain authorities relating to quarantine authority to the CDC. See id. at 2; Control of Communicable Diseases; Apprehension and Detention of Persons With Specific Diseases; Transfer of Regulations, 65 Fed. Reg. 49906-01 (2000).

(54) Kathleen S. Swindiman & Jennifer K. Elsea, Cong. Research Serv.RL33201, Federal and State Quarantine and Isolation Authority, n. 23 (2007), available at See also Control of communicable diseases; apprehension and detention of persons with specific diseases; transfer of regulations. Food and Drug Admin, and Ctrs. for Disease Control & Prevention, HHS. Final rule. 65 Fed Reg. 159 (Aug. 16, 2000), available at
   The Secretary of Health and Human Service (the Secretary) is
   transferring a portion of the Food and Drug Administration (FDA)
   "Control of Communicable Diseases" regulations to the Centers for
   Disease Control and Prevention (CDC). In general, these regulations
   provide the Secretary with the authority to apprehend, detain, or
   conditionally release individuals to prevent the spread of
   specified communicable diseases. The regulations implement the
   provisions of the Public Health Service Act (PHS Act) to prevent
   the introduction, transmission, or spread of communicable diseases
   from one State or possession into any other State or possession.
   CDC will have authority for interstate quarantine over persons,
   while FDA will retain regulatory authority over animals and other
   products that may transmit or spread communicable diseases. The
   Secretary is taking this action to consolidate regulations designed
   to control the spread of communicable diseases, thereby increasing
   the agencies' efficiency and effectiveness.


(55) 42 U.S.C. [section] 264. The statute grants the Surgeon General authority, with the approval of the Secretary, to authorize and enforce regulations to "prevent the introduction, transmission, or spread of communicable diseases from foreign countries into the States or possessions, or from one State or possession into any other State or possession." Id. Such powers are limited to individuals coming into a state from a foreign country. See id.

(56) See id. See also Legal Authorities for Isolation and Quarantine, CTRS. FOR DISEASE CONTROL & PREVENTION (last updated Oct. 8, 2014), available at RegulationsQuarantineIsolation.html (describing legal authorities and CDC's role in isolation and quarantine procedure). The Federal list of communicable diseases is limited to Cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, viral hemorrhagic fever, severe acute respiratory syndromes, and flu that can cause a pandemic. See Exec. Order No. 1367479, Fed. Reg. 45,671 (Jul. 31, 2014); Exec. Order 13375, 70 Fed. Reg. 17299 (Apr. 1, 2005) (Amending Exec. Order No. 13295, 68 Fed. Reg. 17,255 (Apr. 4, 2003)).

(57) See 42 C.F.R. 70.2 (2011) (describing CDC's role if state programs are unequipped to handle suspected quarantine case). See, e.g., Conditions and Principles for Isolation and Quarantine, ILL. ADMIN. CODE tit. 77, [section] 690.1325 (2008). The Illinois administrative code puts forth the conditions for isolation and quarantine, which focus on ensuring that the methods used are the least restrictive means necessary to ensure public safety. Id. The following is an example condition: "... 5) Isolated or quarantined individuals shall be released when the Department or certified local health department determines that the individuals pose no substantial risk of transmitting a dangerously contagious or infectious disease that would constitute a serious or imminent threat to the health and safety of others." Id.
   7) Isolation or quarantine shall not abridge the right of any
   person to rely exclusively on spiritual means (e.g., through
   prayer) to treat a dangerously contagious or infectious disease in
   accordance with religious tenets and practices, nor shall anything
   in this Subpart be deemed to prohibit a person so relying who is
   infected with a dangerously contagious or infectious disease from
   being isolated or quarantined in a private place of his or her own
   choice, provided that the location is approved by the Department or
   certified local health department. The Department or certified
   local health department may isolate infected individuals who
   decline treatment for the period of time they are believed to be
   infectious and may quarantine individuals for the period during
   which they may become infectious.


(58) See 42 C.F.R. [section] 70.3 (2009) (mandating travel restrictions on persons with communicable diseases).
   A person who has a communicable disease in the communicable period
   shall not travel from one State or possession to another without a
   permit from the health officer of the State, possession, or
   locality of destination, if such permit is required under the law
   applicable to the place of destination. Stop-overs other than those
   necessary for transportation connections shall be considered as
   places of destination.

Id. "Communicable period" is defined as "the period or periods during which the etiologic agent may be transferred directly or indirectly from the body of the infected person or animal to the body of another." 42 C.F.R. [section] 70.1 (2009). See also MOSBY'S DENTAL DICTIONARY (2nd ed. 2008), available at (last visited Apr. 17, 2015) (defining "communicable period"). Communicable period correlates to the incubation period of the disease. Id.

(59) See Sydney Lupkin, Ebola in America: Timeline of the Deadly Virus, ABC NEWS, (Nov. 17, 2014, 11:01 am), (providing chronology of recent Ebola outbreak).

(60) See Somini Sengupta, New Ebola Cases May Soon Reach 10,000 a Week, Officials Predict, N.Y. TIMES, Oct. 14, 2014, available at http://www.nytimes.eom/2014/10/15/world/africa/ebolaepidemic-who-west- africa.html?_r=0. The survival rate in most countries infected was approximately 30% in late 2014. Id.

(61) See, e.g., Jacobson v. Massachusetts, 197 U.S. 11 (1905) (holding that state has authority to mandate vaccinations for all state's citizens).

(62) Id. at 35, 39.

(63) See Eugene Kontorovich, Constitutional Challenges to Quarantine Unlikely to Succeed, WASHINGTON POST, Oct. 27, 2014, available at wp/2014/10/27/constitutional-challenge-to-quarantine-unlikely-to-succeed/ (describing similarities between principles of Massachusetts' vaccination laws of 1905 and quarantine regulations).

(64) See U.S. ex rel. Siegel v. Shinnick, 219 F. Supp. 789 (E.D.N.Y. 1963) (upholding mandatory fourteen day quarantine of woman exhibiting no symptoms of smallpox). A daughter petitioned for the release of her mother from federal custody. Id. at 790. The mother had arrived from a trip to Stockholm, which had been declared by the World Health Organization as a smallpox infected area. Id. The court relied on 42 C.F.R. [section] 71.1 (1)(0), which granted the health administration of the suspected infected territory the authority to declare their region infection free. Id. at 790-91.

(65) See Cullen Archer, Ebola Quarantine: Resolving Law with Science, UNIV. OF UTAH S.J. QUINNEY COLL, of L. BlOLAWTODAY.ORG Blog (Nov. 19, 2014), science/#_ftnref47.
   In U.S. ex rel. Siegel v. Shinnick, 219 F. Supp. 789 (E.D.N.Y.
   1963) ... [t]he court deferred to the medical judgment of three
   expert witnesses whose conclusion could not be challenged on the
   ground that they had no evidence of the exposure of Relator to
   smallpox: (1) they were not free to ignore the facts that
   opportunity for exposure existed during her four days in Stockholm;
   (2) no one could know for fourteen days whether or not there had
   been exposure, and (3) Relator's history of unsuccessful
   vaccinations put her in a position to have become infected and to
   infect others.


(66) See U.S. ex rel. Siegel, 219 F. Supp. at 791. "A 'suspect' is one who is considered by the health authority (medical officer in charge) as having been exposed to infection by a quarantineable disease and to be capable of spreading that disease" Id.

(67) See Jennifer Latson, Refusing Quarantine: Why Typhoid Mary Did It, TIME (Nov. 11, 14), available at (discussing Mary Mallon's designation as a typhoid carrier and her subsequent quarandnes).

(68) Id.

(69) See E.M. Leroy et al., Human asymptomatic Ebola infection and strong inflammatory response, LANCET (June 24, 2000), available at (describing scientific study done in Gabon identifying asymptomatic carriers of Ebola); Interview with Martin Rottman M.D., Ph.D., Professor of Clinical Microbiology, UNIV. OF VERSAILLES (Feb. 18, 2015). A recent study done in Nigeria found asymptomatic carriers of the Ebola virus could shed the virus in their urine. Id.

(70) See Michael C. Dorf, Containing Ebola: Quarantine and the Constitution, JUSTIA.COM (Oct. 8, 2014), (describing limitations of personal liberty under quarantine through historical case law).

(71) See U.S. CONST, art. I, [section] 8, cl. 18 (defining Necessary and Proper Clause). "The Congress shall have power ... [t]o make all laws which shall be necessary and proper for carrying into execution the foregoing powers, and all other powers vested by this Constitution in the government of the United States, or in any department or officer thereof." Id. See also U.S. v. Comstock, 560 U.S. 126 (2010) (describing role of Necessary and Proper Clause regarding continued detainment of dangerous inmates post-sentences); supra note 70 (providing background on personal liberties' and public safety).

(72) See U.S. CONST, art. I, [section] 8, cl. 18; Comstock, 560 U.S. at 126.

(73) Sarah Pope et al, Protecting Civil Liberties During Quarantine and Isolation in Public Health Emergencies, LAW PRACTICE TODAY 1 (Apr. 2011), available at publications/law_practice_today_home/law_practice_today_archive/april1/protecting_civil_lib erties_during^quarantine_and_isolation_in_public_health_emergencies.html
   Quarantine and isolation orders must be conducted in accordance
   with substantive and procedural due process, and any restrictions
   of civil liberties should be legal and as minimally restrictive as
   reasonably possible. To this end, states should ensure that the
   following five threshold requirements are met: 1. the individual
   must pose an actual threat to the public; 2. the intervention must
   be reasonable and effective; 3. it must be conducted in a manner
   that comports with equal protection and due process; 4. individuals
   must be provided with safe and comfortable conditions; and 5.
   reasonable compensation for loss of income must be ensured.

Id. at 2.

(74) Id.

(75) Id.

(76) Id. at 1.

(77) See Laurie Garrett, How to Shut Down a Country and Kill a Disease, FORRIGNPOLICY.COM (Oct. 23, 2014), and_kill_a_disease_sars_china_ebola (explaining China's efforts to eradicate SARS in four months through the effective use of quarantine). Within a three-month span, through the effective use of quarantine and monitoring stations, coupled with fast responses from healthcare workers, China was able to essentially contain SARS and prevent its spread. Id.

(78) See Rules For The Implementation of Frontier Health And Quarantine Law (promulgated by Decree No. 2 of the Ministry of Public Health Mar. 6 1989), art. 8 (1989) (China), available at "At the time when any quarantinable epidemic disease is prevalent in certain regions at home or abroad, the health administrative department under the State Council may declare the regions as pestilence areas." Id. at art. 17.

(79) Id. at art. 8.
   In times when quarantinable infectious diseases are prevailing at
   home or abroad, the administrative department of health under the
   State Council shall report the situation to the State Council for
   decisions on taking the following precautionary measures, partially
   or totally, in quarantine inspection: (1) giving orders to blockade
   relevant sections of the border and frontier water course; (2)
   giving orders that certain articles must be disinfected or treated
   with insecticides before they are allowed in or out of the country;
   (3) giving orders to prohibit shipment, in or out, of certain
   articles; (4) giving orders to designate the primary sea-ports and
   airports. Those vessels or aircraft from foreign pestilence areas,
   without going through quarantine inspection at the primary sea-port
   or airport, shall not be permitted to get into any other seaport or
   airport, with the exception of cases of accidents or other special


(80) Id. at art. 3-6 (describing how Chinese authorities limit spread of communicable diseases). Chinese authorities ban the exit and entrance of suspected infected individuals from areas known to contain certain epidemic diseases. Id.

(81) See Garrett, supra note 77 (explaining China's efforts to eradicate SARS in four months through effective use of quarantine). China implemented safety measures seemingly overnight to assess individuals for possible fevers or other signs of SARS. Id.

(82) See Tognotti, supra note 43 (discussing quarantines as a method of controlling infectious diseases).

(83) See Rules for The Implementation of Frontier Health And Quarantine Taw, supra note 78. China's Quarantine Law applies to the Plague, Cholera, as well as Yellow Fever. Id. at art. 68-74, 75-83, 84-92. Each section outlines the incubation period for each disease causing organism, sets forth procedures for foreigners arriving from disease stricken areas, and contamination procedures for vessels carrying disease stricken passengers or cargo such as livestock. Id.

(84) Rules for The Implementation of Frontier Health And Quarantine Law, supra note 78 at art. 63.
   In the situation when the deratization certificate or the
   deratization laissez-passer of a vessel is still valid, but the
   vessel is found to have caught the plague or is suspected to have
   caught the plague, the health and quarantine organ must inform the
   captain that his vessel is required to undergo deratization by
   means of steam sterilization in accordance with the standard set by
   the state, and the captain must act as required.


(85) See Tyson, supra note 30 (presenting Chinese history where China detained sailors and other travelers suspected of plague infected countries).

(86) See Martin Cetron et. al., Isolation and Quarantine: Containment Strategies for SAKS 2003, available at (last visited Apr. 18, 2015) (relaying poor treatment of quarantined individuals).

(87) See Melanie L. McCall, AIDS Quarantine Law in the International Community: Health and Safety Measures of Human Rights Violations? 15 Loy. L.A. Int'l & Comp. L.J. 1001 (1993). "While national health officials have reiterated that no one has a "right to refuse" testing or quarantine, other reports indicate that China has chosen not to implement the quarantine policy because health experts have concluded that such measures are ineffective." Id. at 1007.

(88) See Kristina Peterson & Siobhan Hughes, Ebola: Travelers From Stricken Countries Can Enter at Only 5 U.S. Airports, THE WALL STREET JOURNAL (Oct. 21, 2014 8:56 PM), http://www. ports-1413906804 (describing limiting of flights bound for U.S. from Ebola stricken African countries).

(89) Id. These airline hubs were chosen based on 94% of the roughly 150 individuals traveling from Liberia, Guinea and Sierra Leone that already entered the United States through one of these destinations. Id. On average, estimates suggested that these entrance restrictions would only burden roughly nine people per day who would need to seek an additional domestic flight to reach their destination, after being screened at these airports. Id.

(90) See Cecilia Kang, New York Revises Controversial Policy on Ebola Quarantines Amid Pressure,

WASHINGTON Post (Oct. 26, 2014), quarantines-amid-ebola-threat-draw-criticism-as-governors-defend actions/2014/10/26/00eff94c-5d22-11e4-8b9e-2ccdac31a031_story.html (reporting on Congressional response from New York and New Jersey governors amidst Ebola scare).

(91) Id.

(92) Ebola nurse Kaci Hickox Back in Home State of Maine, WEARTV, features/tracking-ebola/stories/53751-Ebola-nurse-Kaci-Hickox-back-in-home-state-of-Maine. shtml (last visited Apr. 18, 2015).

(93) Id.

(94) Id. See U.S. CONST, amend. XIV, [section] 1.

"No state shall make or enforce any law which shall abridge the privileges or immunities of citizens of the United States; nor shall any state deprive any person of life, liberty, or property, without due process of law; nor deny to any person within its jurisdiction the equal protection of the laws."

Id. See also Esme D. Deprez et. al., Ebola Nurse Defeats Quarantine Demands on Judge's Ruling, BLOOMBERG Business (Oct. 31, 2014 11:00 AM), available at news/articles/2014-10-31 / nurse-hickox-ordered-to-follow-ebola-quarantine-rules-ap-says (describing legal recourse Nurse Hickox undertook to regain freedom).

(95) Id.

(96) See Robert F. Bukaty, Kaci Hickox Wins in Ebola Case: Judge Rejects Maine's Bid to Quarantine Nurse, WASHINGTON Times (Oct. 31, 2014), available at 2014/oct/31/kaci-hickox-wins--judge-rejects-ebola-quarantine/ (discussing Nurse Hickox's battle against Maine for her forced quarantine).

(97) Id.

(98) Id:

(99) See id. (informing that only those who show symptoms are purported to be infectious).

(100) New York, New Jersey Set Up Mandatory Quarantine Requirement Amid Ebola Threat, CBS NEWS, (Oct. 24, 2014), atory-quarantine-requirement-amid-ebola-threat/ (last visited Apr. 20, 2015). Governor Cuomo, whose state was treating Dr. Craig Spencer, just returning from a volunteer trip for the non-profit organization Doctors Without Borders, commented after treatment of Ebola patients, "Voluntary quarantine--you know it's almost an oxymoron. This is a very serious situation." Id. The New York physician had passed the airport screening at John F. Kennedy airport, as he arrived with no symptoms. Id. See also Jamie Schram et. al., Ebola Hits NYC: Doctor Gets Virus, Fiancee and 2 Friends Quarantines, N.Y. POST, Oct. 23, 2014, positive-for-deadly-ebola-virus/. However, after a night of bowling and a ride in an Uber taxi, the doctor developed a fever and was immediately hospitalized at Bellevue hospital. Id.

(101) See U.S. CONST, amend. X (giving rights to the states that are not delegated to the federal government); New York, New Jersey Set Up Mandatory Quarantine Requirement Amid Ebola Threat, supra note 100 (discussing New York and New Jersey procedures regarding hospitalization and quarantine).

(102) See Matt Flegenheimer et al., Under Pressure, Cuomo Says Ebola Quarantine Can Be Spent at Home, N.Y. TIMES, Oct. 27 2014, at Al, available at ebola-quarantine.html (explaining measures instituted in New York and New Jersey).

(103) See Jacobson v. Massachusetts, 197 U.S. 11, 31 (1905) (upholding states' authority to enforce compulsory vaccination laws). Jacobson refused to comply with the town's order for all adults to be vaccinated and argued his liberty was "invaded when the State subjected] him to [a] fine or imprisonment for neglecting or refusing to submit to vaccination." Id. at 26. Jacobson claimed that the vaccine made him seriously ill as a child. Id. at 36. He was then ordered to pay a fine, which he refused. Id. at 26. Jacobson argued in court that the compulsory inoculation violated both the Massachusetts and United States Constitution. See id. at 28. He claimed the Fourteenth Amendment gave him the right to refuse the vaccine. See id. at 29-30. After hearing arguments, Justice John Marshall Harlan acknowledged that for some, the vaccine would be cruel and inhumane due to medical reasons, so he set forth medical exemptions to the vaccination laws. Jacobson, 197 U.S. at 38-39. However Harlan claimed that Jacobson did not fall under this exemption. Id. See also Viemeister v. White, 72 N.E. 97 (N.Y. 1904). Police powers belong to every sovereign state, and may be "exerted by the legislature subject to the limitations of the constitution, whenever the exercise thereof will promote the public health, safety or welfare." Id. See also Lawrence O. Gostin, Jacobson v. Massachusetts at 100 Years: Police Power and Civil Liberties in Tension, 95 Am. J. PUBLIC HEALTH 576 (2005) (describing importance of considering certain standards to protect constitutional rights of individuals).

(104) See Executive Order--Revised last of Quarantinable Communicable Diseases, The WHITE HOUSE (July 31, 2014), communicable-diseases. The President has revised the list of quarantinable communicable diseases, which already classified Ebola as a "quarantinable communicable disease." Id. See also Michael C. Dorf, Containing Ebola: Quarantine and the Constitution, JUSTIA.COM (Oct. 8, 2014), States are given the power under the Constitution's Article I, Section 10 to enact and enforce "inspection laws." Id. These powers are congruent with the states' Tenth Amendment right to quarantine. Id. The federal government may assist the states with their enforcement of quarantine laws as delegated by the 1796 and 1799 federal statutes, which allowed the federal government '"to assist in the execution of the quarantine and health laws of the states." Id. The distinction drawn is the importance that the federal government may assist the states in enforcing states' quarantine measures, however the federal government may not order state officials to implement a quarantine. Id. For federal authority to enforce quarantines, the court would need to find that the spread of the communicable disease would affect interstate commerce. Id. The devastation that could occur from the spread of a disease such as Ebola transcends individual harm and could take a major toll on economic prosperities of countries. Dorf, supra note 70. See also supra note 51 (describing Commerce Clause).

(105) See Immigration and Nationality Act, U.S. CITIZENSHIP & IMMIGRATION SERVS., (last updated Sept. 10, 2013) (describing purpose of the act). See also Immigration and Nationality Act of 1952, Pub. L. No. 414, 182 Stat. 66 (1952) (codified as amended in scattered sections of 8 U.S.C). The Immigration and Nationality Act was passed in 1952 and restricted the types of immigrants who could enter the United States. Id. See generally Law Orgad, Article, Creating New Americans: The Essence of Americanism Under the Citizenship Test, 47 HOUS. L. Rev. 1227, 1237 (2011). Although President Harry Truman initially vetoed the Act, for he thought it to be racially discriminating, his vote was overridden by the House and the Senate. Id. The majority wanted to grant unlimited entrance to immigrants with special skills and families of United States residents while restricting everybody else. Id. See generally 1952 Immigration and Nationality Act, a.k.a. the McCarran-Walter Act, UNIV. OF WASHINGTON-BOTHELL LIBRARY, immigration_and_nationality_act.html (last visited Apr. 20, 2015) (providing summary of the Immigration and Nationality Act of 1952).

(106) Symposium, Twenty- Second Annual Health Law Symposium: Twentieth Annual International Law Symposium: "Global Perspectives On HIV AND AIDS:" Global Health Governance and International Law, 25 WHITTIER L. Rev. 253 (2003). The regulation, monitoring and control of AIDS statute were implemented in 1988 and describe the requirements for the control of AIDS in China. Id. at 265. The exit and entry procedures for all Chinese citizens require that each individual's health certificate be monitored. Id. at 266. The specific statute, Article 7(4) of the National Frontier Act describes that "[a]n alien suffering from mental disorder, leprosy, AIDS, venereal diseases, contagious tuberculosis or other infectious diseases [shall not be allowed to enter China]." Id. at 267. See also Julia Preston, Obama Lifts a Ban on Entry Into U.S. by H.I.V.--Positive People, N.Y. Times, Oct. 31, 2009, at A9, available at politics/31travel.html (reporting Bush initiated process to remove HIV off the Communicable disease list). Bush initiated the process of removal from the list and a year later, in 2008, President Obama announced the official lifting of the twenty-two year old ban. Id.

(107) See Michael Carter, China repeals its HIV' travel ban, AIDSMAP (Apr. 28, 2010), (describing how China removed ban on HIV positive foreign travelers into China).

(108) See Ebola: Transmission, CTRS. For DISEASE CONTROL & PREVENTION, (last updated Apr. 19, 2015) (describing the transmission mode of Ebola). The first natural reservoir host of Ebola is thought to be an infected primate. Id. The first infection likely took place through contact with the infected primate, which is known as a spillover event. Id. The virus is thought to be spread between humans via direct contact with blood or bodily fluids or contaminated objects of infected Ebola persons or infected fruit bats or primates. Id. Ebola may also be spread as a result of bushmeat or mosquito or other insect bites though no clinical data is available to prove or disprove this means of transmission. Id. See also HIV Transmission, CTRS. FOR DISEASE CONTROL A7 PREVENTION, (last updated Jan. 16, 2015). HIV transmission is through contact with certain fluids such as blood, semen, rectal fluids, and breast milk. Id. The fluids must come in direct contact with a mucous membrane or a damaged tissue. Id.

(109) Compare Ebola Transmission, supra note 108 (explaining how a person contracts Ebola) with HIV Transmission, supra note 108 (explaining how a person contracts HIV).

(110) See Frequently Asked Questions about ATRV, CTRS. For DISEASE CONTROL & PREVENTION, (last updated July 2, 2012) (discussing SARS disease and its transmission); Ebola Transmission, supra note 108 (describing Ebola and how the disease is transmitted).

(111) See Matthew J. DeFazio, Article, Guarding International Borders Against HIV: A Comparative Study In Futility, 25 PACE Int'l L. Rev. 89, 106-07 (2013) (discussing China's HIV restrictions in order to protect the public). In 2006, on World AIDS Day, President George W. Bush announced the United States would be taking steps to remove the HIV travel ban. Id. at 100. This statement resulted in Congress proposing the "HIV Nondiscrimination in Travel and Immigration Act of 2007." Id. This Act was not officially passed, however it is credited for the regulation that annihilated this AIDS travel ban years later in 2010. Id.

(112) See David P. Fidler, Return of the Fourth Horseman: Emerging Infectious Diseases and International Law, 81 Minn. L. rev. 771, 774 (1997) (discussing ease of transmission of high virulent and contagious disease in modern day society).

(113) See Garrett, supra note 77 and accompanying text (describing Chinese SARS outbreak and response).

(114) Fact Sheet for SAKS Patients and Their Close Contacts, CTRS. FOR DISEASE CONTROL & PREVENTION, (last updated July 2, 2012). SARS is a viral respiratory illness that spread from China to two-dozen countries within two months. Id. Due to its transmission through respiratory systems, the risk of transmission is extremely high. Id. Symptoms of the virus include fevers, headache, dry cough, shortness of breath, and most notable decreased oxygen level in the blood leading to pneumonia. Id.

(115) Severe Acute Respiratory Syndrome--Singapore 2003, CTRS. FOR DISEASE CONTROL & PREVENTION, available at (last visited Apr. 20, 2015) (describing first three SARS patients traveling Singapore to Hong Kong during initial Chinese SARS outbreak). There were up to 201 probable cases and 722 suspected cases have been estimated. Id.

(116) See SAKS, Public Health, and Global Governance: Article: SAKS and International Legal Preparedness, 77 TEMP. L. Rev. 155 (2004) (evaluating immediate measures China took in wake of an unknown and new disease).

(117) See Garrett, supra note 77 (reporting methods China employed to prevent spread of SARS by installing medical units overnight and implementing fever checkpoints). See also Elanah Uretsky, Can the lessons of SARS Help Stop Ebola, THE NATIONAL INTEREST, (Oct. 30, 2014) available at (last visited Apr. 20, 2015) (covering similarities in disease mortality and ease of transmission between Ebola and SARS). Understanding the disease epidemiology can aid the United States implementing similar measures to prevent the spread of Ebola. Id.

(118) Garrett, supra note 77 (discussing fever check point stations that Chinese utilized to contain people with fevers)

(119) Id.

(120) Id.

(121) Id. China's method of SARS control was not perfect. Id. A study done by the CDC showed that had China limited the quarantined criteria to those who had contact, defined as at least a thirty minute exposure with a known SARS patient, China could have reduced the number of those quarantined by sixty six percent. Id. See also Efficiency of Quarantine During an Epidemic of Severe Acute Respiratory Syndrome--Beijing China, CTRS. FOR DISEASE CONTROL & PREVENTION (Oct. 31. 2003), (discussing survey conducted by CDC regarding SARS and quarantines and controlling future outbreaks). See generally See Natasha Khan, Why China's SARS legacy May Give It an Edge Against Ebola, BLOOMBERG Business (Oct. 30, 2014), give-it-an-edge-against-ebola.

(122) U.S. CONST, amend. X. "The powers not delegated to the United States by the Constitution, nor prohibited by it to the states, are reserved to the states respectively, or to the people." Id.

(123) U.S. CONST, art. I, [section] 8, cl. 3. The Commerce Clause gives Congress the power "to regulate commerce with foreign nations, and among the several states, and with the Indian tribes." Id.

(124) See Cetron, supra note 86 (describing principles of modern quarantine and strategies China employed to prevent the spread of SARS).

(125) Id.

(126) Id.

(127) Ebola Virus Disease, WORLD HEALTH ORGANIZATION (Apr. 2015), mediacentre/factsheets/fs103/en/. Good epidemic outbreak control regulations rely on case management, surveillance, and contact tracing. Id. Of these methods, reducing the risk of human-to-human transmission either from direct or close contact with people with Ebola symptoms needs to be in effect. Id. More importantly, outbreak containment measures, which include identifying people who may have been in contact with the infected individual, must be monitored for twenty-one days. Id. WHO stresses the "importance of separating the healthy from the sick to prevent further spread." Id.

(128) See Steven Beutler, We Should Quarantine Everyone Coming From Countries With Ebola Outbreaks, NEW REPUBLIC (Oct. 16, 2014), available at says-infectious-disease-doctor. Ebola is transmitted via bodily fluids and not by respiratory transmission. Id. An Ebola outbreak in the United States is more probable than might otherwise be believed due to the following factors: 1) emergency rooms are too busy to establish a correct diagnosis; 2) breaks in infection control policies, such as maintaining proper personal protection gear; 3) contact tracing is a daunting process, particularly since most contacts will not be recognized until after they become ill, given the long incubation period Ebola, and 4) lack of proof that patients are not contagious before they show symptoms considering they are infected with the virus. Id. Additionally, it is still possible that the disease could spread via sexual transmission or even something as innocuous as a nosebleed. Id.

(129) Larry Buchanan et al., Retracing the Steps of the Dallas Ebola Patient (last updated Oct. 8, 204), available at /us/retracing-the-steps~of-the-dallas-ebola- patient.html?_r=0 (discussing Duncan's exposure, treatment and ultimate death from Ebola virus).

(130) Id.

(131) See Ebola (Ebola Virus Disease), CTRS. FOR DISEASE CONTROL & PREVENTION (Apr. 3, 2015), (discussing Ebola symptoms, transmission, treatment, prevention and risk of exposure).

(132) See Josh Voorhees, Everything That Went Wrong in Dallas, SLATE (Oct. 2014), meline_the_many_medical_missteps_at_texas_health_presbyterian.html (describing timeline of infection the nurses caring for Duncan experienced).

(133) Id.

(134) See Cetron, supra note 86 (discussing quarantine as a containment strategy).

(135) See Ebola: Mapping the Outbreak, BBC NEWS (Apr. 13, 2015), available at (discussing the locations impacted by the 2014 Ebola outbreak).

(136) 8 U.S.C. [section] 1158. See Immigration and Nationality Act, U.S. CITIZENSHIP & IMMIGRATION SERVICES (Sept. 19, 2013), (describing the Immigration and Nationality Act of 1952 also known as the McCarran-Walter Bill). See also Milestones: 1945-1952 The Immigration and Nationality Act of 1952 (The McCarran-Walter Act), U.S. Dep't of State Office of the Historian, available at (last visited Apr. 19, 2015). The Immigration and Nationality Act reinforced the system of immigrant selection based on preferences based on skill sets and family reunification. Id. The restrictive selection system for immigration heavily favored immigration from northern and western Europe. Id. Roughly 85% of the 154,277 visas issued annually were provided to these individuals. Id. Favoritism caused resentment toward the United States in many other parts of the world. Id. The selective immigration system was upheld as ensuring the preservation of national security and national interests. Id. For Asian immigrants, a minimum quota of 100 visas each year was allotted for each Asian nation. See U.S. DEP'T OF STATE OFFICE OF THE HISTORIAN, https://history. (last visited Apr. 19, 2015). At this time, laws banning Asian immigrants from being naturalized were eliminated and slowly United States relations with these Asian nations improved. Id. Under this selective immigration system, individuals with special skills or those who had families already with United States residency could receive preference. Id. This preference still plays an active role in current United States immigration policy. Id.

(137) See Gostin, supra note 32 (describing earliest municipal ordinances for quarantine laws and consequential affects of each ordinance). Quarantine has been practiced at a local level in the United States since the first municipal ordinance was enacted in Boston in 1647. Id. at 424. Subsequently, other municipalities started to enact similar ordinances such as East Hampton, Long Island in 1662 and New York in 1663. Id. Before long, states were themselves enacting quarantine statues to prevent the entry and spread of foreign diseases, Massachusetts and New York both enacted such statues. Id. Once the Constitution was drafted, quarantine had become a widely accepted practice in the United States. Id.

(138) Quarantine and Isolation, supra note 44. See also Tognotti, supra note 43 (clarifying purpose of quarantine to separate and restrict movement of diseased, enforcing state of isolation). The term is not analogous to medical isolation, which serves the purpose of separating ill persons who have a communicable disease from those who are healthy. Id. Quarantine is meant to last only as long as necessary, meaning periods can be very short or very long depending on the length of time needed to extinguish the threat of spread of disease. Id. Historically, the international community has met on numerous occasions to discuss the optimal way to enforce quarantines; examples include the Venice convention in 1892 where thirty nations met to address the growing cholera concern near the Suez Canal, Paris, Dresden, and Venice. Id. A further example of an international convention is the multilateral international sanitary convention in Paris in 1912 where forty countries met to discuss growing sanitation concerns. Id.

(139) Tyson, supra note 30 (describing history of quarantine laws and how it has affected society).

(140) Tyson, supra note 30. In 1930, any immigrant arriving at the immigration station on New York's Ellis Island, and who appeared to have some sort of communicable disease, was immediately segregated from the general population. Id. These immigrants would undergo medical exams and if it was determined that they were in fact sick, they would be quarantined in a hospital until they were no longer contagious. Id. See also Ellis Island Oral Histories, supra note 30 (recollecting Ellis Island as immigrant detention center, not quarantine station to separate contagious from healthy). For example:
   Nelly Ratner (Myers) was both Jewish and deaf, making her and her
   deaf family especially vulnerable targets when Nazi Germany marched
   into her hometown of Vienna in 1938. She, her mother and sister
   were lucky enough to take the last ship allowed to travel from
   Italy to the U.S., spending Yom Kippur on board. Upon their
   arrival, they discovered that immigration officials saw a deaf
   family as a burden. They spent months at Ellis Island. Despite her
   deafness, Myers could speak.

Id. See also Latson, supra note 67 (describing Mary Mallon, asymptomatic carrier of Salmonella Typhi, died in quarantine after infecting over fifty).

(141) Id.

(142) Id.

(143) Tyson, supra note 30 (describing history and overall effects of quarantine laws).

(144) See ELLIS ISLAND: Through America's Gateway, supra note 30. Between 1892 and 1954, over twelve million immigrants were processed at Ellis Island. Id. The immigration stations expanded over three connected islands and included structures such as hospitals and infectious disease wards. Id. Prior to 1920, "Ellis Island mirrored the nation's generous attitude and open door policy." Id. However, after the enactment of the immigration laws of 1920, Ellis Island had become known for '"assembly, detainment, and deporting aliens,' and symbolized a closing door." Id.

(145) Id. See also Latson, supra note 67. Prior to being quarantined, Mary Mallon infected over fifty people with salmonella Typhi, before subsequently dying in isolation. Id. Mary fought the quarantine stating that she was being persecuted without having done any harm. Id.

(146) Id.

(147) Cetron, supra note 86 (describing medical procedures forced on immigrants).

(148) See ELLIS ISLAND: Through America's Gateway, supra note 30. About two percent of those coming to the United States were turned away at Ellis Island and sent back to their home countries, from where they attempted to escape poverty, violence, or disease. Id.

(149) Cetron, supra note 86. By 1914, the Immigration hospital at Ellis Island was fully operational with over 10,000 patients from seventy-five different countries having been treated the previous year. Id. Doctors would use metal calipers to measure the circumference of immigrants' heads to determine the "superior racial stock" that would be favored when determining who could stay in the United States. Id. The Ellis Island hospital was also where many alleged mentally ill patients would be detained in the psychiatric ward. Id. Many of those detained in the psychiatric ward were not actually mentally ill, but due to cultural and language barriers, as well as their anxiety due to being detained in a foreign land, these immigrants appeared mentally ill to those evaluating them. Id.

(150) Id.

(151) Latson, supra note 67.

(152) See Specific I ^am and Regulations Governing the Control of Communicable Diseases, supra note 50 (discussing rights provided by states and federal governments' regarding quarantine powers).

(153) See Conditions and Principles for Isolation and Quarantine, ILL. ADMIN. CODE tit. 77, [section] 690.1325 (2008) (describing laws in place for quarantine must be done using least invasive means).

(154) Id.

(155) See Schram, supra note 100 (describing activities of Dr. Craig, post Ebola exposure).

(156) Id. See also supra note 7 (describing speed disease may spread via seemingly innocuous encounters individuals engage in on day-to-day basis).

(157) See United States v. Comstock, 560 U.S. 126, 137 (2010) (describing role of Necessary and Proper Clause regarding continued detainment of dangerous inmates post-sentences); Jacobson v. Massachusetts, 197 U.S. 11, 31 (1905) (deciding that vaccination program had substantial relation to public health and safety).

(158) See Jacobson, 197 U.S. at 26 (finding relation between vaccine programs and protecting public health).

(159) Id.

(160) See Bukaty, supra note 96 (discussing battle between Nurse Hickox and Maine).

(161) Id. See also United States ex rel. Siegel v. Shinnick, 219 F. Supp. 789, 790 (E.D.N.Y. 1963) (discussing quarantine of woman after returning from smallpox infected area).

(162) Shinnick 219 F. Supp. at 790 (upholding mandatory fourteen day quarantine of woman exhibiting no symptoms of smallpox).

(163) Id. See also Deprez, supra note 94 (describing legal recourse Nurse Hickox undertook to get her freedom back).

(164) See Comstock, 560 U.S. at 133-34 (holding that Necessary and Proper Clause authorizes enactment of statute in questions); Shinnick, 219 F. Supp. at 790-91 (upholding Public Health Regulations that authorize detainment); Jacobson, 197 U.S. at 31 (confirming statute in question does not infringe upon individual rights).

(165) See Garrett, supra note 77 (describing China's efforts to eradicate SARS by means of quarantine).

(166) See Shinnick, 219 F. Supp. at 790.

(167) See supra note 92 (recounting Nurse Hickox's Ebola quarantine). See also supra note 108 and accompanying text (describing contagion and transmission of Ebola).

(168) See supra note 6 and accompanying text (outlining study of asymptomatic carriers); Rottman, supra note 69.

(169) See Comstock, 560 U.S. at 133-34; Shinnick, 219 F. Supp. at 790-91; Jacobson, 197 U.S. at 31. See also Bukaty, supra note 96 (describing course of legal action taken by Nurse Hickox, leading to eventual victory).

(170) See supra note 83 and accompanying text (describing rules and implementation of China's Quarantine Act).

(171) See Uretsky, supra note 117 (comparing similarities in transmission of Ebola and SARS); supra note 169 (listing United States case law upholding use of quarantine).

(172) See supra note 121 and accompanying text (noting that eradication was accomplished by somewhat imperfect system of containment).

(173) Garrett, supra note 77 (discussing how China was able to maintain SARS within three month period).

(174) Id

(175) Id

(176) Id

(177) Id

(178) See Rules for the Implementation of Frontier Health and Quarantine Law of the People's Republic of China, supra note 78, at Article I.

(179) 42 USCS [section] 264(a) (2011) (outlining Surgeon General's authority to implement and enforce regulations to prevent spread of communicable diseases).

(180) See Tyson supra note 30 and associated text (describing evolution of quarantine lengths relating to incubation period for the specific disease causing pathogen or virus). Modern science can now determine incubation periods, which allows for more specific guidance in setting appropriate quarantine periods. Id.

(181) See id. See also Jacobson v. Massachusetts, 197 U.S. at 28-30; Gostin, supra note 103, at 579 (describing constitutional protections set forth in the Jacobson v. Massachusetts decision). When affirming Massachusetts' compulsory vaccination law, the court established that in order to support public health safety, four standards that needed to be taken into consideration to ensure constitutional protections: "necessity, reasonable means, proportionality, and harm avoidance." Id. at 576.

(182) Id. See also supra notes 74-77, and associated text.

(183) See supra notes 45-49 (describing role of CDC in determining optimal incubation periods for infectious viruses and microorganisms). See also Waterman, supra 43, at 203-11.

(184) See supra notes 180-183, and associated text.

(185) See supra note 77 (focusing on China's procedure for quarantining for SARS).

(186) See Ebola Virus Disease, supra 127, and associated text (explaining incubation period is between 2 and 21 days).

(187) Garrett, supra note 77 (describing quarantine procedures served dual purpose: helping at-risk individuals, protecting public from SARS).

(188) See supra note 127 (describing incubation period for virus is twenty one days). It is important to monitor the health of individuals who may have been in contact with the disease for twenty-one days and to separate the healthy from the sick. Id.

(189) Administrative Code, Tide 77, supra note 57 (describing the least restrictive means approach).

(190) See Cetron, supra note 86 (explaining quarantine measures must align with modern public health principles).

(191) See id. (detailing how quarantine strategies become part of "public health toolbox").

(192) Id.

(193) See Garrett, supra note 77 (describing quarantine measures utilized in China during SARS outbreak such as fever-check stations); Cetron, supra note 86; McCall, supra note 87 (discussing human rights issues regarding quarantine measures in China).

(194) See Garrett, supra note 77; see Bukaty, supra note 96.

(195) See Khan, supra note 121 (describing how China's strategy to fight SARS and HINI will better prepare it for Ebola). "In the last 10 years, they've [China] built up massive capacity to respond to this kind of situation, to avoid damage to public health and prevent the socio-economic problems that arise with it." Id.

(196) Garrett, supra note 77 (editorializing that quarantine measures must be taken if backed up with scientific advice).

(197) See id. (describing routine mandatory fever checks and no tests confirming patient had SARS before being quarantined).

(198) See supra note 117 and accompanying text (noting SARS was new and scientific data was unavailable at outset of outbreak in China).

(199) See supra note 117 and accompanying text.

(200) See supra note 117 and accompanying text.

(201) See supra note 117 and accompanying text.

(202) See Cetron, supra note 86 (stating that Nigeria eradicated Ebola transmissions within its boundaries as declared by World Health Organization).

(203) See Cetron, supra note 86 and accompanying text.

(204) See id.

(205) See id.

(206) Id.

Nazita Gamini, J.D. Candidate, Suffolk University Law School, 2016; M.S., University of Massachusetts Amherst, 2010; M.S., University of Massachusetts Amherst, 2009. Ms. Gamini may be contacted at
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Title Annotation:severe acute respiratory syndrome
Author:Gamini, Nazita
Publication:Journal of Health & Biomedical Law
Date:Mar 22, 2015
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