The Bush administration is taking initial steps to plan for a potential military role in enforcing a massive quarantine, if smallpox or another highly contagious virus were to break out somewhere in the United States,
defense officials tell Inside the Pentagon.
Talks have begun among various federal agencies that could delineate a role for U.S. troops, should local and state law enforcement authorities become
overwhelmed, officials say.
This week a congressionally mandated commission on homeland security said the military should begin preparing for the possibility that “rapid-response”
forces will be needed in such a case.
The commander of U.S. Northern Command — the military organization assigned to defend the American homeland from attack — must have “dedicated, rapid-reaction units with a wide range of response capabilities such as an ability to support implementation of a quarantine,” states a new report from the Gilmore Commission. The panel was created four years ago to advise the president and Congress on domestic response to terrorism involving weapons of mass destruction.
The possibility of a biological attack on the United States is receiving increased attention as the nation contemplates war against Iraq, which experts fear may have “weaponized” smallpox, anthrax or other biowarfare
agents. On Dec. 13, President Bush announced a plan to vaccinate almost 500,000 military personnel against smallpox, beginning immediately, and to start inoculating up to 10 million medical workers and emergency responders shortly thereafter.
Administration officials say the nation soon will have stockpiled enough smallpox vaccine to inoculate all Americans within days after an outbreak occurs. The vaccine is believed to be effective as many as four days after exposure to the disease. Without rapid treatment, this once-eradicated virus is deadly.
“Our government has no information that a smallpox attack is imminent,” Bush said last week. “Yet it is prudent to prepare for the possibility that terrorists who kill indiscriminately would use diseases as a weapon.”
Existing public health plans call for local and state officials to institute and enforce a quarantine, if necessary, in which individuals who may have been exposed to a contagious disease — but show no ymptoms — are confined and physically separated from those who have not been exposed.
But some federal officials, public health analysts and national security experts anticipate a large-scale quarantine would almost surely incite public panic and could require the use of federal troops to restore order. Defense officials emphasize military forces would act solely in a support role to federal civil authorities in such a domestic mission.
Controlling the spread
In the case of even a limited outbreak of a highly contagious disease like smallpox, plague or yellow fever, health officials may call for a broad
geographic area to be sealed off, officials say. That is because an infected individual might come into casual contact with dozens of people days before
developing or identifying symptoms. Simply breathing within six feet of another person can spread the smallpox virus.
A common example of a large quarantine is the creation of a perimeter around a city like Cincinnati, OH, so that no one may leave or enter on foot or by vehicle, train, aircraft or boat. Such a quarantine might be lifted for individuals who remain symptom-free for a period of time, or could be eliminated en masse after an outbreak has been contained, sources said.
But depending on the extent of the outbreak, a quarantine could remain in place — potentially in multiple U.S. cities or regions simultaneously — for
weeks, months or even years.
“Is there any doubt in your mind if a single case of smallpox is discovered that the troops would be in there in a flash?” asks Stephen Dycus, a specialist in national security law on the faculty of Vermont Law School. “I don’t have any doubt, because smallpox or pneumonic plague are highly contagious,” and both have a latency period that increases the risk of a
rapid spread, he said.
“As soon as word gets out, there’s going to be panic in the population,” Dycus said in a Dec. 17 interview.
“There will have to be quarantines on a massive scale.”
Experts imagine scenarios in which large numbers of parents, seeking to protect their families, attempt to flee a city in which one or more smallpox cases have been identified. Conversely, a mother or father who is out of town during an outbreak would almost certainly want to return to a quarantine zone to care for their children.
Although local and state health officials are the first line of defense — and a governor can call up the National Guard under Title 32, if necessary, to enforce a quarantine — Pentagon and federal civil authorities are concerned state and local law enforcement capabilities may quickly become overwhelmed.
Particularly in situations where smallpox has been discovered simultaneously in multiple cities, the federal government anticipates getting involved in
the response.
Guidelines for “isolation and quarantine” published by the Centers for Disease Control and Prevention note that federal regulations authorize action by CDC “in the event that measures taken by local and state health
authorities are insufficient to prevent the spread of smallpox to other states.”
Title 42 of the U.S. Code says health regulations “may provide for the apprehension and examination of any individual reasonably believed to be infected with a communicable disease in a communicable stages,” who is moving from one state to another or in contact with a person in transit. “Such regulations may provide that if, upon examination, any such individual is found to be infected, he may be detained for such time and in such manner as may be reasonably necessary,” states the law.
Title 42 suggests the U.S. surgeon general, with approval from the secretary of health and human services, has the authority to make and enforce
regulations in this regard. However, experts say in the case of a bioterrorism attack, health policy decisions that begin on a local or state level would likely elevate quickly to the U.S. president.
The Posse Comitatus Act, which generally prevents U.S. military forces from engaging in domestic search and seizure, includes exceptions that allow the use of federal troops to restore civil order in national emergencies. Legal experts believe an outbreak of smallpox may well justify the involvement of U.S. troops.
How much force?
But if military personnel are deployed to enforce a quarantine, what level of force could they use to stop the movement of individuals seeking to leave or enter a quarantine area? Experts cite concerns about domestic missions for a military generally trained to use lethal force more readily than local law enforcement. Should troops be allowed to shoot someone trying to escape quarantine, given the risk of widening a limited smallpox outbreak into an epidemic?
“You should use the lowest degree of force necessary to achieve the end in view,” says Eugene Fidell, a former Coast Guard judge advocate general now in private practice. He says a bio-terror attack “strikes me as a 21st century equivalent of a natural disaster that could potentially involve the breakdown of civil order.”
But the U.S. military should plan for non-lethal force in such a case, using devices for crowd control, rubber bullets and warning shots, he said.
Fidell described a massive quarantine as “a siege in the public interest.”
CDC envisions the creation of a “cordon sanitaire” or “line around a quarantine area guarded to prevent spread of disease by restricting passage into and out of the area,” according to the organization’s published
guidelines. Concentric circles of quarantine might be established that allow for various levels of restriction.
If just a single case of smallpox has been discovered, “isolation and quarantine measures can be implemented on a voluntary basis,” CDC states. But
a wider outbreak may necessitate “population-wide quarantine measures which restrict activities or limit movement of individuals,” according to CDC.
Prior to a smallpox attack, CDC recommends public officials identify “relevant legal authorities, persons and organizations empowered to invoke and enforce” a quarantine, build “public trust and compliance with government directives,” and vaccinate “personnel required to implement and enforce quarantine measures.”
As the federal government kicks off its inoculation campaign, the other two imperatives have barely begun implementation, experts note.
Dycus says CDC draws upon a confusing set of statutory and regulatory authorities in planning to handle communicable disease outbreaks. He says a number of critical factors remain undecided:
* Whether CDC has the authority to mandate that persons — citizens, legal and illegal residents, and visitors — undergo physical exams or inoculations, or take pharmaceutical drugs;
* Who has the authority to declare a quarantine or determine the criteria for ordering one; and
* Who will determine the geographic scope, duration, or allowable activities in a quarantine.
The Gilmore Commission — named for its chairman, James Gilmore, the former Republican governor of Virginia — also advises the federal government to review the statutory basis for establishing quarantines.
The new U.S. national strategy for homeland security “appropriately calls for a review of legal authority for use of the military domestically,” states the panel’s fourth report, released Dec. 16. “But other legal and regulatory issues must be addressed, not the least of which are quarantine, isolation [of those symptomatic or exposed], mandatory vaccinations, and other prescriptive measures that may be called for in the event of a biological attack.”
The Gilmore Commission recommends the president direct the attorney general to conduct such a review of applicable laws and regulations immediately, and
“recommend legislative changes before the opening of the next Congress.”
Informing the public
Dycus and others say public information is among the most important elements currently missing. If the federal government recognizes the need to plan for a potential smallpox quarantine, “we should do it openly,” he says.
Others say a massive quarantine may actually be unworkable, with panicked individuals perhaps triggering the very spread of disease that the quarantine aims to contain.
Planning should focus on less Draconian measures, says retired Air Force Col. Randy Larsen, director of the ANSER Institute for Homeland Security. The kind
of small-scale quarantines the World Health rganization used to eradicate smallpox in African and Indian villages in the early 1970s will not work in
today’s “densely populated, highly mobile, unvaccinated” U.S. population, he told ITP this week.
The Gilmore Commission notes that following the 2001 anthrax mailings, which resulted in deaths in New York, Washington and Florida, “only 44 percent of those instructed to complete a 60-day course of Cipro actually did so. This does not bode well for quarantine, isolation, vaccination or other public
health measures.”
The federal government should focus its planning on a public information campaign and massive inoculations, to be implemented immediately upon discovering a large-scale smallpox attack, Larsen says.
Mass vaccinations of the entire public would be difficult but not impossible, following the model of getting 100 million Americans to the voting booths
every Election Day, Larsen says. Both quarantines and public inoculations should be highly recommended, but made voluntary, he says.
“Many health care workers will say that people must be forcibly quarantined,” Larsen wrote in a July white paper. “I disagree. Those who do not receive the
vaccine will not be a threat to those of us who choose to vaccinate our families.”
Public health experts note, though, that additional people may be at risk. The smallpox vaccine is not recommended for pregnant women, young children,
or those with skin conditions or weak immune systems. The latter includes people with the AIDS virus, many cancer patients and those who have recently received organ transplants. But these individuals would be encouraged to take the vaccine if risk of smallpox exposure were high.
“Imposition of large-scale quarantine . . . should not be considered a primary public health strategy in most imaginable circumstances,” a group of physicians wrote in a December 2001 article in the Journal of the American Medical Association. “In the majority of contexts, other less extreme public health actions are likely to be more effective and create fewer unintended
adverse consequences than quarantine.”
A broad information campaign is an essential part of the federal government’s planning for responding to a smallpox outbreak, one defense official said this week, speaking on condition of anonymity. “But will it be effective? Probably not,” said the official, noting that more rigous alternatives must be planned in case they become necessary.
