Boston Globe
October 8, 2005


[RPR introduction: President Bush said he attacked Iraq to avert harm
from weapons of mass destruction, arguably a precautionary action.
Some say this shows that the precautionary principle is fatally
flawed. Now the President says he wants to use the army to quarantine
civilians on U.S. soil to prevent a pandemic of bird flu, ostensibly
another precautionary action. In this essay, George Anas argues that
a quarantine is unlikely to prevent a pandemic, and may prove harmful
in other ways.

Proponents of precaution need to think carefully about whether
wrongheaded precautionary actions prove that the idea behind the
precautionary principle itself is flawed -- the idea that we should
use the best information we've got to evaluate available alternatives,
and choose the least harmful. -- The RPR Editors.]

By George J. Annas

Whenever the world is not to his liking, President Bush has a tendency
to turn to the military to make it better. The most prominent example
is the country's response to 9/11, complete with wars in Afghanistan
and Iraq. After Hurricane Katrina, Bush belatedly called on the
military to assist in securing New Orleans, and has since suggested
that Congress should consider empowering the military to be the
"first responders" in any national disaster.

On Tuesday, the president suggested that the United States should
confront the risk of a bird flu pandemic by giving him the power to
use the US military to quarantine "part[s] of the country"
experiencing an "outbreak." So we have moved quickly in the past
month, at least metaphorically, from the global war on terror to a
proposed war on hurricanes, to a proposed war on the bird flu.

Of all these proposals, the use of the military to attempt to contain
a flu pandemic on US soil is the most dangerous. Bush says he got the
idea by reading John Barry's excellent account of the 1918 Spanish flu
pandemic, "The Great Influenza." Although quarantine was used
successfully in that pandemic, on the island of American Samoa, Barry
in his afterword suggests (sensibly) that we need a national plan to
deal with a future influenza pandemic. He said last week that his
other suggestions were the only ones he hoped public health officials
and ethicists would consider, but they read like policy
recommendations to me and apparently the president. Barry writes, for
example, "if there is any chance to limit the geographical spread of
the disease, officials must have in place the legal power to take
extreme quarantine measures." This recommendation comes shortly after
his praise for countries that "moved rapidly and ruthlessly to
quarantine and isolate anyone with or exposed to" SARS.

Planning makes sense. But planning for "brutal" or "extreme"
quarantine of large numbers or areas of the United States would create
many more problems than it could solve.

First, historically mass quarantines of healthy people who may have
been exposed to a pathogen have never worked to control a pandemic,
and have almost always done more harm than good because they usually
involve vicious discrimination against classes of people (like
immigrants or Asians) who are seen as "diseased" and dangerous.

Second, the notion that ruthless quarantine was responsible for
preventing a SARS pandemic is a public health myth. SARS appeared in
more than 30 countries; they all reacted differently (some used forced
quarantine successfully, others voluntary quarantine, and others no
quarantine at all), and all "succeeded." Quarantine is no magic

Third, quarantine and isolation are often falsely equated, but the
former involves people who are well, the latter people who are sick.
Sick people should be treated, but we don't need the military to force
treatment. Even in extremes like the anthrax attacks, people seek out
and demand treatment. Sending soldiers to quarantine large numbers of
people will most likely create panic, and cause people to flee (and
spread disease), as it did in China where a rumor during the SARS
epidemic that Beijing would be quarantined led to 250,000 people
fleeing the city that night.

Not only can't we evacuate Houston, we cannot realistically quarantine
its citizens. The real public health challenge will be shortages of
health care personnel, hospital beds, and medicine. Plans to
militarize quarantine miss the point in a pandemic. The enemy is not
sick or exposed Americans -- it is the virus itself. And effective
action against any flu virus demands its early identification, and the
quick development, manufacture, and distribution of a vaccine and
treatment modalities.

In 1918 the Spanish flu was spread around the US primarily by
soldiers, and it seems to have incubated primarily on military bases.
It is a misreading of history that a lesson from 1918 is to militarize
mass quarantine to contain the flu. And neither medicine nor public
health are what they were in 1918; having public health rely on mass
quarantine today is like having our military rely on trench warfare in

What has not changed in the past century, however, is the fact that
national flu policy will be determined by national politics. In World
War I, as Barry recounts, this policy demanded that there be no public
criticism of the federal government.

That policy was a disaster, and did prevent many potentially effective
public health actions. Today's presidential substitution of a military
quarantine solution for credible public health planning will also be
counterproductive and ineffective in the event of a real pandemic. It
would leave US citizens sick with the flu to wonder -- like the
citizens of New Orleans told to go to the Convention Center and the
Superdome for help -- why the federal government had abandoned them.

Public health in the 21st century should be federally directed, but
effective public health policy must be based on trust, not fear of the

George J. Annas is chairman of the Department of Health Law, Bioethics
and Human Rights at Boston University School of Public Health and
author of "American Bioethics."

Copyright 2005 The New York Times Company