By Rachel Kaplan Hoffmann, M.D., M.S.Ed., and Keith Hoffmann, J.D.
Peer Reviewed
On December 6, 2013, a two-year-old boy living in southeastern Guinea became the first victim of the latest epidemic of Ebola Virus Disease (EVD). Since the death of Patient Zero, EVD has spread throughout West Africa, becoming the largest outbreak of the deadly virus ever [1]. In its most recent report (2/18/15), the World Health Organization (WHO) reported over 20,000 cases of EVD, with over 9,000 reported deaths [2], but the actual number of infections may be higher, due to difficulties diagnosing and reporting the disease in rural areas [3]. In the destructive wake of the outbreak, impoverished African nations sought to prevent the spread of the disease with the limited resources at their disposal. The rebirth of the cordon sanitaire, a primitive form of contagion containment, to prevent the recent EVD outbreak’s spread raises a host of ethical issues.
The cordon sanitaire is a French term dating from the 17th century that means “sanitary cordon.” It denotes a disease outbreak-control method in which a quarantine zone is determined and those inside are not allowed to leave [4]. Traditionally, the line around a cordon sanitaire was quite physical; a fence or wall was built, a regimen of armed troops patrolled, and, inside, terrified inhabitants were left to battle the affliction without outside help. First developed during the Black Death of the Middle Ages, cordons sanitaires have since been used to quarantine inhabitants of Georgia, Texas, and Florida during the 1880s to combat the spread of yellow fever; Honululu’s Chinatown during a bubonic plague outbreak in 1900 [5]; and Poland during a typhus outbreak after World War I [6]; along with historical examples that include infected communities voluntarily cordoning themselves [7]. These cordons achieved varying levels of medical success; at their worst, cordons sanitaires, including most American examples of the practice, have been examples of callousness and racism that unnecessarily victimized minority communities. However, an EVD outbreak in 1995 in Kikwit, Zaire was reportedly contained by “heartless but effective” cordons sanitaires [8].
The initiation of cordons sanitaires in the current EVD crisis was announced on August 1st after an emergency public health summit of the three nations most affected by the EVD outbreak was held in Conakry, Guinea [9]. Government and public health officials of the Mano River Union bloc representing Guinea, Sierra Leone, and Liberia, determined that the highly affected cross-border region between the three nations—a triangular area where 70% of the then-reported EVD cases were located—would be isolated by police and military. Soon after, The New York Times reported that large sections of Sierra Leone, and areas north of Liberia’s Capital, Monorovia, had military road-blocks where soldiers checked credentials and took temperatures of those going in or out [10]. Since the Mano River Union bloc of nations initiated these cordons sanitaires, the quarantines did not remain peaceful: four people were injured after police opened fire on the West-point slum in,Monrovia where between 50,000 and 100,000 people were cordoned [11]. Those quarantined stated that the barbed wire of the cordon sanitaire prevented them from accessing food and leaving the area for work—many people were starving. The slum’s inhabitants also attacked a quarantine center, looted mattresses and other goods, and helped suspected EVD patients to escape—evidence of the fear, desperation, and misunderstanding of the disease among the cordoned inhabitants.
In addition to these regional, city, and neighborhood-wide cordons sanitaires, the Financial Times reported that several less-affected African nations, including Ivory Coast, Chad, South Africa, Kenya and Senegal initiated travel, trade, and border restrictions with the three highly affected western countries [12]. Senegal completely closed its boarder with Guinea. Regional and international airlines halted flights into the hardest-hit countries. In our increasingly interconnected world, millions of uninfected citizens were being isolated out of fear of a few thousand infected.
The question has remained whether these cordons sanitaires are ethical. A WHO spokesperson stated that “[t]his is an extraordinary event in so many ways and with this extraordinary event extraordinary measures are probably going to be necessary. [The WHO] would not be against a cordon sanitaire, but it must respect human rights.” According to the New York Times, other health organizations, including the CDC, stated that such tactics could be effective, but must be used humanely in order to be ethical. The provision of food, water, and medical care to those inside a cordon, and a good line of communication with leaders inside the cordon are cited as examples of humane use of a cordon sanitaire [13]. However, the WHO stopped short of endorsing cordons that cover large geographic areas. In a statement, the WHO indicated that no general ban on international travel or trade should be implemented, due to detrimental effects on international relief efforts and the trade of necessities like food and clothing. Rather, the WHO endorsed exit screening (consisting of, at a minimum, a questionnaire, temperature assessment, and evaluation of unexplained fevers) of persons at international airports, seaports, and major land crossings to identify people with potential EVD infection. But even these limited international cordons, along with localized cordons, raise similar ethical issues.
When evaluating the cordons sanitaires according to the useful framework of the four fundamental ethical principles of autonomy, beneficence, non-maleficence and justice; it becomes questionable whether cordons sanitaires are an ethical medical practice [14]. Cordons limit many competent adults’ autonomy about their care by limiting their ability to leave a cordoned area. Furthermore, the beneficence of quarantines for some—those outside of cordons—must be balanced against non-maleficence, or the responsibility not to harm those who are cut off from the outside world by a cordon; these quarantined persons are not only exposed to disease, but may find difficulty obtaining food, water, sanitary living conditions, and work for as long as an infection danger remains within a cordon. With regard to the principle of justice, a cordon sanitaire may devalue the lives of those within a cordon, unequally distributing the burdens a disease places upon an entire society.
The ethical theories of the cordon sanitaire stand in opposition to the pragmatic utilitarianism offered by philosophers like Jeremy Bentham, who advocates taking actions that achieve the greatest good for the greatest number of people. During a disease outbreak, and the breakdown of society such outbreaks can cause, ethical theories may give way to the practical goal of containing the immediate spread of disease. According to Laurie Garrett, a public health expert and Fellow of the Council on Foreign Relations who was present during the 1995 EVD outbreak in Kikwit, Zaire, the cordons can be effective in controlling outbreaks. She warns that current efforts may be too little, too late, but urges that controlling the current outbreak will require the imposition of strict cordons sanitaires [15].
In the current outbreak, these cordons have had variable effectiveness. Clinically, very small-scale cordons—quarantining individual patients and those with whom EVD patients have come into direct contact—have demonstrated effectiveness [16], while medium- and large-scale cordons around neighborhoods, regions, and nations have proven ethically troubling, largely ineffective, and difficult to enforce, as even wealthy nations like the United States have found border control to be porous. Large-scale cordons also present the possibility of devastating effects on national economies and public health.
Thus, public health officials should focus on the containment of EVD by zeroing in on those already infected and containing its spread through small-scale cordons sanitaires—like those that have been successful in Nigeria and Senegal—conducted in the most ethical manner possible. Fortunately this type of effort has demonstrated effectiveness; in their most recent report, the WHO states that on a national level, Guinea, Liberia, and Sierra Leone have achieved the capacity to isolate and treat all reported EVD cases and to bury all EVD-related deaths safely and with dignity. They still note that local variations exist and the average capacity is insufficient in some areas to isolate the disease [17]. These smaller-scale cordons will be unable to prevent people like the first EVD patient in the United States from travelling from West Africa to the United States while incubating the virus. But a strict focus on small-scale cordons will prevent the sorts of blunders that occurred in Dallas, where an emergency department initially failed to diagnose the patient, and those with whom he had direct contact were not effectively quarantined even after public health officials learned of the patient’s diagnosis [18]. Even while strictly enforcing small-scale cordons, public health officials should be vigilant to prevent unnecessarily harsh or capricious cordons as inappropriate quarantines raise ethical issues, may create public health panic, and waste resources [19].
After treating a healthcare worker affected by EVD at Bellevue Hospital, NYU health care practitioners have gained firsthand insight into the vast human and medical resources that must be utilized to prevent the spread of just one case of EVD [20]. This public health challenge allowed New York’s health care establishment to gain greater understanding of the ethical, legal, and financial struggles faced by nations attempting to contain a very contagious disease like EVD; we must note that this struggle is amplified in countries where medical care is less advanced and basic resources much more limited. We should continue to prepare our medical response so that future quarantines are done in the most ethical and effective manner possible, because this will not be the last time an infectious disease outbreak must be contained through the brutally pragmatic use of limited cordons sanitaires.
The Inherent Quandary of Medical Ethics. Commentary by Antonella Surbone MD PhD FACP, Ethics Editor, Clinical Correlations.
The article entitled “Ethical Considerations in the Use of Cordons Sanitaires” by Rachel Kaplan Hoffmann and Keith Hoffmann presents an insightful analysis and discussion of the ethical implications of the practice of Cordon Sanitaires, as it is now applied to limit the potential widespread diffusion of Ebola virus infections. In their concluding statement, the Authors say that “We should continue to prepare our medical response so that future quarantines are done in the most ethical and effective manner possible, because this will not be the last time an infectious disease outbreak must be contained through the brutally pragmatic use of limited cordons sanitaires.”
In clinical medicine, whether applied to individuals or populations, we often find a surreptitious and troublesome admixture of brutality and tenderness, which are rarely discussed as part of professionalism or medical ethics. I shall offer some brief reflections.
Clinical practice, based on both distance and intimacy at physical, psychological and spiritual levels, may entail radical acts, such as invasive diagnostic procedures or complex interventions, that occur under the overarching principles of attention and solicitude for the sick person entrusted to our care, or the highest good for populations. These contrasting elements generate tensions that can result in expressions of brutality or of tenderness, at times simultaneously. Tenderness, a quality of being moved to compassion and of being warmheartedly responsive to others, is always expressed in delicate manners. In response to patients’ suffering, tenderness reveals grief over patients’ anguish through gentle gestures. Brutality is rather reflected in crude actions or behaviors that may be incisive and accurate but always are harsh, physically painful or invasive, and devoid of human mercy or compassion.
The technological interventions of modern medicine often come with major physical intrusion, which can be, or be perceived by patients and their families as a form of brutality that may be exacerbated or mitigated by the conduct of doctors, nurses, and others members of the clinical team.
A different brutality is the one described by the Authors, of severe restrictions of liberty associated with highly contagious infectious diseases. This brutality can also be mitigated by the compassion and tenderness of those courageous health care workers who provide medical care and assistance, while sharing to some extent the risk of being infected.
The question to ask ourselves here is, in the case of the ‘brutally pragmatic use of limited cordons sanitaires’ are we facing an inherent quandary of medical ethics or are we giving in to political considerations that benefit wealthier countries and protect affluent populations over those who already live in dire poverty? In the latter case, we would not be facing an inherent quandary of medical ethics, but yet another a socio-political injustice. We, as ethical physicians and nurses, are committed to care tenderly for all our patients.
Dr. Rachel Kaplan Hoffmann is a 2nd year resident at NYU Langone Medical Center
Peer reviewed by Antonella Surbone, MD, PhD, FACP, Ethics Editor, Clinical Correlations
Image courtesy of Wikimedia Commons
References
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