Thanks, Andrew Speaker

Last month, one man single-handedly exposed the fact that the US public health system doesn't always do its job. Infected with a deadly drug-resistant strain of tuberculosis, Andrew Speaker traveled to several countries, exposing more than 600 people on two flights, even though a scan of his passport brought up a warning to keep him in custody and contact health authorities. One could argue that it's the public health system's fault that he developed extremely drug-resistant tuberculosis (XDR-TB) in the first place. TB becomes resistant to antibiotics when improperly treated, and XDR-TB is resistant to at least two main first-line drugs and at least three of the six second-line drugs. If we thoroughly treated TB in its less deadly-form, the US Centers for Disease Control and Prevention wouldn't have had to institute its first federal quarantine in nearly 45 years. It is clear that our current system of directly observed tuberculosis therapy, in which healthcare workers watch patients take their TB medicine, may not sufficiently ensure that people receive appropriate treatment and cure. Although the incidence of TB in the United States reached its lowest point in 2005 (4.8 cases per 100,000), that same year, the rate of decrease showed one of the smallest declines in more than 10 years. Moreover, the number of people with drug-resistant strains of TB increased by 13% between 2003 and 2004 (the most recent data) - the biggest increase since 1993. Infectious disease control has not significantly advanced since the 14th century, when quarantine was the preferred method for controlling the spread of plague in Europe. The name quarantine comes from the Italian "quaranta giorni," or 40 days, the period of time that merchant ships were sequestered when returning from infected regions. Now, the meaning of quarantine is often less specific than it was in Italian harbors seven centuries ago. During recent drills for combating bioterrorism, US officials have confusingly used the word to describe a number of different containment strategies, including limiting travel, restricting public gatherings, and isolating infected people. Even now, the rules about quarantine don't seem crystal clear. The CDC ultimately decided that Speaker had a quarantine-worthy strain, and local officials told him not to travel with TB. According to the CDC, the only enforcement in place was a "covenant of trust," which obviously wasn't enough. So what should local health officials, or the federal government, have done differently? Quarantining people against their will could easily be interpreted as a violation of civil liberties. (In an interesting twist, Speaker is a personal injury lawyer, and his father-in-law is a prominent TB researcher at the CDC.) History contains many incidents during which imposing quarantine went horribly wrong. In the late 19th century, the New York Port Authority placed ships traveling from regions hit with a cholera outbreak under quarantine, but it did not care for all passengers equally, and the disease spread rapidly among the poor. In 1900, in response to a plague outbreak, officials established a quarantine on only Chinese residences and businesses in San Francisco, causing severe economic damage to the community. A federal court later ruled that the quarantine was unconstitutional. So, officials didn't violate Andrew Speaker's liberties, but what about the interests of all the airplane passengers who spent hours with him, and now need to go through the trouble of getting tested and protecting their family and friends? There is more to public health ethics than protecting civil liberties. We have not yet, as a society, thought through collectively how we want to handle, from a public policy perspective, events that are highly unlikely (the CDC recorded less than 50 cases of XDR-TB from 1993 to 2006), yet could be catastrophic. So whose rights and interests come first during public health challenges: Andrew Speaker's or those of the general public? That question, still unanswered, is as old as quarantine itself. We need a better public-health surveillance system, better disease monitoring, and better ways of thinking about rare but devastating events. The scientific community can help by offering policymakers suggestions about how to: refine TB therapies to be more effective, improve surveillance mechanisms for the detection of MDR and XDR-TB, and assess the kinds of risks patients like Andrew Speaker pose to the public's health. We can only hope that Andrew Speaker will not be a harbinger of things to come, but rather a wake-up call to what we need to do better. Glenn McGee is the director of the Alden March Bioethics Institute at Albany Medical College, where he holds the John A. Balint Endowed Chair in Medical Ethics.gmcgee@the-scientist.com

Thanks, Andrew Speaker

One man with TB shows the world why the quarantine system often doesn't work.

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