Quarantine won’t work. Never has. There are two reasons why.
The first is epidemiological. Despite numerous attempts throughout history, quarantine efforts have shown very little value in stopping an epidemic.
We know this and we know why. Infectious diseases are quite good at what they do, which is to be fruitful and multiply. Influenza, with its airborne droplet and casual contact transmission modes, is one of the most highly infectious of the lot. People nearing the end of the incubation phase of an infection, still feeling perfectly healthy, are shedding virus at maximum rates and are, therefore, maximally infectious. Thermal scanners won’t pick them up.
I qualified my statement, writing “very little” instead of “no”, because there is one historical incident in which quarantine seems to have been partially successful: it comes from Australia’s attempts to keep the 1918 Pandemic out of this country. Then, quarantine of shipping probably delayed introduction of the epidemic into Australia until early in 1919. This spared Australia from the first and second, deadliest, waves of transmission. The third wave was far less virulent.
But that was only a partial success, achieved at a time when the fastest means of personal transport was on horseback and the only means of intercontinental travel by ship. If Cordon sanitaire couldn’t be completely affected, despite vigorous effort, under those conditions, it is hubris to think it would work with today’s speed of travel and volume of human movement.
The second reason quarantine won’t work is human nature. Strict social controls are anathema to free peoples.
Social controls work in highly regimented, closed societies. If Kim Jong Il says jump, 22 million North Koreans obediently (fearfully) cry out “how high?” in unison.
Now imagine standing in front of a group of homecoming Aussies, tired and worn out from a long journey (even if it is a hedonistic vacation), and informing them that they shouldn’t go home. Any idea what responses you’d get? They wouldn’t be in unison, either.
The public now perceives swine flu as being no worse than seasonal flu. In the decision criteria most people will employ faced with the alternatives of enforced confinement (hotel, fever ward, cruise ship), vs. going home, or voluntary confinement at home vs. going to work in an economic environment where a job is to be protected at all costs, the choice of disregarding the government edict will be an easy one to make. And one that fits the larrikin Australian psyche.
In public health we are damned if we do and damned if we don’t. There is much glory to be gained in jumping into the fray when a catastrophe strikes and doing your bit to mitigate the effects of a disaster. Prevention success, resulting as it does in a non-event, carries no glamour.
Let’s assume for the moment that we do follow a policy of enacting strict social control measures, with harsh penalties for non-compliance. Now let’s make the more tenuous assumption that they provide some, but not complete, disruption of transmission. Let’s say 15% reduction in morbidity.
Such a reduction would justify such measures. But since this would be a real time intervention and not a controlled study, we would only be able to estimate the actual benefits. Now, what is the likely result? Would the public heap praise on the public health effort, rejoicing in the smaller peak in the graph of the epidemic curve? Or would they focus on the loss of business and freedom of movement and the civil sanctions imposed on those who violated quarantine. Would they cry “heroes” or would they cry “nanny state”?
Hudson Birden is Senior Lecturer, Public Health & Clinical Leadership, at the NSW North Coast Medical Education Collaboration
If we were to replace the word morbidity with mortality in the case where the flue was far more lethal that this particular one, would this argument carry the same weight and would we have had the extremely half hearted response from our governments that we have had.
It would be interesting to hear from Hudson Birden on whether Tamiflu/Relenza can play a role. That is, will it always be a case of bolting the barn door too late, or is it possible to think of mandating that all travellers to/from the source country (for a killer flu, most likely China) commence a course of these drugs before travelling back? And will this swine-flu outbreak tell us how realistic/effective these drugs are in stopping/slowing these epidemics?
Would it not be a good idea to confront those homecoming holiday makers and others who are (or were three weeks ago) many times as likely to be a source of the swine flu virus with Tamiflu or Relenza and the advice and request to start taking them immediately and complete the course? There would, presumably, be little chance of producing resistance since Australians on the whole, are likely to follow instructions to complete the course, and, anyway, most would not be infected at all. Which brings us to the question of there being any problem about taking the anti-flu drugs unnecessarily, given that the cost is not a serious problem on the scale required by the suggestion. Harmful side effects? What else?
Would the efficacy of such prophylactic use of the anti-flu drugs depend to a considerable extent on their making people who were infected less infectious to others? Presumably the viral load of any sneeze would be less if a person brewing the disease had been taking Tamiflue or Relenza for a couple of days?
Seems to me (at the risk of sounding Stalinist or Northkoreanista) that your post is more about social control than swine flu. I was delighted, last weekend when I entered Nicaragua on an overland trip from El Salvador, that the government there had put health department officials and volunteers on duty with masks and alcohol hand washes, to take the details of each arrival … where they came from, and where they were going. Brilliant strategy to construct a useful database if swine flu did pop up in their little nation state. I’m not paranoid about Swine Flu … in fact I am planning to do several of those horrific thirty hour bus trips overland through Mexico to catch my flight back from LA. But paranoia about ‘social control’ is almost as deadly a meme as the swine flu paranoia virus itself. In El Salvador there have been eleven cases (probably because noone comes here). In Nicaragua there have been none. It reminds me of the time I was in Nicaragua in 1997 when hurricane Juana devestated the Caribbean. Neighbouring Costa Rica suffered 500 casualties. Honduras and El Salvador some 5 or 6 thousand. Nicaragua had one … a drunk who wandered into a storm water channel at the height of the hurricane. Meanwhile the reactionary Catholic Church was abusing the Sandinista government for the ‘forced relocation of the inhabitants of Bluefields on the Atlantic Coast into concentration camps’. Okay, Bluefields was wiped out, but noone was killed, and the town was rebuilt with Cuban aid, but we don’t hear that in the Washington Post.
Okay .. excuse the rant but I just wanted to say i respect the efforts of the government of Nicaragua to mitigate the effects of swine flu, and that I resent the efforts of Hudson to portray these efforts as ‘social control’.
I know that Swine Flue is not mortal. But the number of times that I have contracted a terrible attack of infuenza on bus trips from Nimbin to Canberra leads me to appreciate the efforts of the Nicaraguan government to keep their people sound and sane.
Unlike some of Crikey’s more reactionary correspondents.
what are the risks that premature use of tamiflu/relenza on a benign(ish) pandemic will reduce its ability to be used effectively, when the big one hits?
-G