Bioethics Forum Essay
Another Pragmatic Public Health Decision
There has been much criticism of the decision by the Centers for Disease Control and Prevention (CDC) to let Covid-infected people who are feeling better to stop quarantining after five days and simply wear a mask. Most of the concern stems from the fact that up to 31% of people in this category will actually still be infectious. Among the reasons given by CDC Director Rochelle Walensky is to “keep society functioning” by allowing airlines and other businesses to stay open. In addition, those being told to quarantine for 10 days were not necessarily complying.
Although countenancing potentially infectious people to return to circulation may seem surprising for a public health agency, it is actually the sort of pragmatic decision that the CDC and other health officials have consistently made for decades. Revisiting some of this history can put current attempts to stop the spread of Covid-19 into perspective.
Perhaps the most famous public health controversy of the 20th century was smallpox vaccination. Like Covid-19, smallpox was an epidemic disease that came in waves. Devastating, it killed up to one-third of those infected and left major scarring (from healing pox lesions) in another one-third. Vaccination of healthy individuals was a proven way to prevent spread of the disease.
When Cambridge, Massachusetts faced a growing outbreak of the disease in 1902, it passed a regulation mandating that citizens either get vaccinated or pay a $5 fine. Henning Jacobson, a Lutheran minister who had reacted badly to other shots, refused to pay the fine. His case ultimately went all the way to the U.S. Supreme Court. In 1905, the court ruled in favor of Massachusetts, stating that “there are manifold restraints to which every person is necessarily subject for the common good.”
While this decision codified the power of public health officials to limit behaviors during a crisis, it is worth noting what Massachusetts did not do. It did not force people to get vaccinated. By requiring payment of $5 (admittedly a lot of money then), it permitted unvaccinated citizens to travel freely.
Why was this policy chosen? Being more aggressive would have been impractical both politically and logistically. The hope was that the fine would successfully induce enough of the population to get vaccinated and thus mitigate the epidemic.
A half century later, health officials took a different tack with tuberculosis. By the 1950s, drugs were finally available to treat the communicable and often fatal lung disease, but certain people would not take their medications properly, leading to ongoing infections and drug-resistant strains of the bacterium.
In Seattle, nonadherence predominated among itinerant workers, often suffering from alcoholism and psychiatric illness, who lived in the city’s Skid Row section. Into the early 1970s, city health officials forcibly detained thousands of men, many of whom were no longer actively infectious, in the city’s tuberculosis sanatorium, to force them to take their pills and be cured. Seattle was able to do this because these individuals—predominantly men—were a disadvantaged population with little legal recourse to fight the city.
In part as a reaction to what happened in Seattle, doctors now employ a less aggressive approach. Called directly observed therapy, it requires persons with tuberculosis to take their medications in front of a trained monitor either in a clinic or at home until their disease is cured.
Directly observed therapy is an example of a less restrictive alternative, a policy that guards the public’s health but tries to honor the rights of the affected individual. It is also an example of harm reduction, a common public health strategy for managing behaviors and lowering negative consequences.
Is directly observed therapy perfect? No. There are patients who miss their appointments and even disappear for periods of time. Still, completion rates are as high as 90%, which is an excellent success rate for a complicated disease with complicated therapy.
A final example of a practical public health approach is that of drunk driving. Well into the 1970s, drunk driving was a largely unacknowledged epidemic, killing as many as 25,000 Americans annually. Drunk drivers, even those with prior arrests, often received slaps on the wrist, even when they killed or injured others.
Thanks to Mothers Against Drunk Driving (MADD) and other groups, activist campaigns began in the 1980s, leading to more stringent laws and punishments as well as the popularizing of concepts such as the designated driver. Ultimately, the legal blood alcohol level in The U.S. was lowered from 0.15% to 0.08%. As a result of this, sobriety checkpoints and other restrictions, deaths from drunk driving have decreased to roughly 10,000 annually .
Is that number still too high? Of course, but pushing for stronger restrictions has consistently met with political opposition, from those of a libertarian bent as well as restaurant owners and beverage companies worried about the viability of their businesses. Even MADD does not support lowering the blood alcohol limit to 0.05%, which is used in many other countries.
Should everyone infected with Covid-19 stay home for 10 days and then test themselves to make sure they are not infectious before going out? Ideally, yes. But this scenario conflicts with the practical realities of keeping society running and the reluctance of fully vaccinated, asymptomatic people to stay home two years into an ongoing pandemic. As such, the CDC, like past health officials, has made a practical decision that is reasonable.
But for those of you leaving quarantine after five days, realize the privilege you are being given. If you are able to stay home for longer, please do so. If you have access to antigen and/or PCR testing, please try to obtain one and strongly consider remaining home if you are still positive. And try to get N-95 or KN-95 masks which will further lower the chances of your spreading Covid-19 to someone else. Citizens should take seriously genuine efforts to construct public health policies that are both effective and practical.
Barron H. Lerner, MD, PhD, (@barronlerner) a professor of medicine and population health at New York University Langone Health, is the author of One for the Road: Drunk Driving Since 1900. He is a Hastings Center fellow.