Mandatory Quarantine: Lessons from 1980s Cuba


By: Rushnan Anusha

Rushnan Anusha is a 2021 graduate from the University of Toronto, with a double major in Global Health and Bioethics. Having previously worked for the Ontario Ministry of the Attorney General for two years, her academic and professional interests centre around understanding the legal, political, and ethical questions surrounding rapidly evolving biotechnology.


Often in times of crises (i.e., a pandemic), we take for granted the necessity of actions undertaken to combat said crises. But this breeds complacency — we risk becoming beholden to status quos without thinking critically about what we are doing, why, and whether being in crisis is truly enough to justify our actions. As such, with Ontario’s second wave battle underway (at the time this paper was originally written), I thought it critical to analyze the public health motivations behind mandatory quarantines, their ethical implications, and if/when such measures go too far.


In this paper, I will explore whether it is ethically permissible for the state to mandate the quarantine of infectious individuals with the purpose of repressing epi/pandemics. Drawing on principles of utilitarianism, beneficence, non-maleficence, autonomy, and justice; and through the examples of Canada’s present-day COVID-19 quarantines and Cuba’s confinement of HIV+ individuals in the 1980s, I argue that while mandatory quarantines themselves are not generally problematic, the conditions surrounding their implementation may render them ethically impermissible.

Defining ‘Quarantine’

It is important, first, to differentiate between mandatory quarantines and its close relatives, the stay-at-home and lockdown orders. In Canada, mandatory quarantines and isolation are imposed on those who have recently traveled abroad or have a confirmed, expected, or suspected positive diagnosis of COVID-19 (1). Stay-at-home orders, in contrast, are imposed on the general population – not exclusively those who are or may be infectious. In Ontario, this amounts to restricting the populace from congregating in public places, limiting how many people can be present in closed-spaces, regulating socialization between people of different households. Lockdowns, relatedly, necessitate the closure of public venues so as to limit interactions between numerous people (2).

Thus, while all three are similar (and so, the arguments laid-out henceforth may be applicable to them all), quarantines (the specific focus of this paper) are the state-mandated isolation of people with infectious diseases, while the others concern the population as a whole; they all, however, share a common purpose of repressing epi/pandemics and stopping the spread of infectious diseases.



Arguments for Mandatory Quarantine

One of the endgames during a(n) epi/pandemic is to stop the spread of disease and to protect the health and wellbeing of whole populations as much as possible. So, from a utilitarian perspective, mandatory quarantines are morally justified and required, as they effectively maximize the most good for the most number of people. Quarantines – isolating infectious people so they cannot further spread disease and infect even more people – ensure the greatest amount of good for the greatest number of people (3). By restricting the movement of a few people, we ensure the safety and protection of all others, and curb the burden of a widespread outbreak and epi/pandemic. In doing so, we also promote beneficence and non-maleficence. Promoting beneficence requires that we promote that which is ‘good’; during a pandemic, this ‘good’ is encapsulated in maintaining the physical health and wellbeing of a population with respect to the viral outbreak. Alternately, upholding a duty towards nonmaleficence requires minimizing that which is ‘harmful’ -- in this case, the physical illness and disease that runs rampant during a pandemic. Mandatory quarantines intrinsically promote both beneficence and nonmaleficence. By isolating those who carry an infectious disease, quarantines protect the physical health and wellbeing (the ‘good’ outlined above) of everyone else (3). At the same time, they also advance and abide by non-maleficence, by actively preventing the general public from falling victim to the physical illnesses and disease that follow upon contracting an infectious disease. It could even be argued that the state and its public health officials fail in upholding a duty to non-maleficence if they do not implement quarantine measures because they would thereby increase the risk of their citizens falling ill (perhaps even fatally so) (4).

Moreover, the prevailing arguments against mandatory quarantines are derived from principles of autonomy and justice. Those who oppose mandatory quarantines tend to argue that regardless of its efficiency and efficacy in containing epi/pandemics, quarantines infringe upon the autonomy of those who are confined. Citizens are free and independent and vested with the power of self-determination and autonomous choice; thus, regardless of the public health aims and purposes of quarantine orders, the state is not justified in mandating the isolation of its citizens and restricting (5). Additionally, they may argue that doing so is actually unjust – enforcing mandatory quarantines for those with infectious diseases unfairly punishes them for something they did not (presumably) choose to inflict upon themselves, in favour of protecting everyone else.

However, these arguments are both flawed. They take for granted that individual autonomy is the supreme principle that the state and its public health officials must uphold. However, this is neither sensical nor appropriate, especially when the health and safety of entire populations are at stake. The right to individual autonomy extends only insofar as its exercising does not harm others (6) – and this is something we already readily accept in most societies. Almost all negative and prohibitive laws restrict the actions of individuals in order to protect the populace at large; citizens are free and autonomous to do what they choose, only up until this autonomy poses a credible threat of harm to some other person. The most common negative laws (i.e., those against murder, stealing, assault, drunk driving, rape, etc.) all restrict the liberty of some in order to protect others who may be endangered by said liberty. Though we may be free and independent persons within a society, our autonomy is limited regarding acts that may potentially harm other parties. As such, it is illogical to argue that mandatory quarantines are unethical due to the restrictions they place on individual autonomy when such restrictions are something we generally readily accept; in fact, these restrictions on autonomy may be even more justified in times of epi/pandemics when the health and wellbeing of entire populations are in question.


Not All Quarantines Are Created Equal

While mandatory quarantines in and of themselves may not be problematic, not all are equally as ethically permissible, on account of how and why they are implemented, as well as for how long, amongst other factors. The key example of this is Cuba’s HIV sanitariums. Cuba, from the 1980s, has had the lowest rates of HIV prevalence in the Caribbean (the second-highest HIV-inflicted region in the world) (7). This was partly achieved through their National AIDS Program, which included the mandatory quarantine of all HIV+ individuals, from 1986-1994, in sanitariums – facilities/compounds specifically created for this purpose. The conditions of these facilities were reported as being favourable and pleasant, though patients were separated from their families and loved ones and given indefinite information regarding how long their quarantine would last

(7, 8).

Cuba’s quarantines were immensely successful in curbing the spread of an infectious disease by isolating patients from the general population, and the sanitariums themselves do not appear to pose any concerns regarding living conditions. Yet, the sanitariums are (and were) generally considered to be ethically unjustifiable and a highly controversial public health policy, due to their dehumanizing treatment of HIV+ patients. The present COVID-19 quarantines, in contrast, are by and large far more accepted and considered ethically justifiable, even though the end goals of both are essentially the exact same. The difference in Cuba’s sanitariums is that the devaluing of individuals is impermissibly prevalent and overwhelming, while the same cannot be said for the quarantine measures in Canada for COVID-19. Carting off all HIV+ patients into isolated sanitariums for an undetermined and indefinite amount of time treats them as means to an end (lowering rates of HIV) to the point of dehumanizing them. The sanitariums seem less like public health measures to curb the spread of HIV and more like prisons for those who are infected to serve out (what was presumably thought to be at the time) a life sentence. In contrast, the COVID-19 quarantines are for a maximum of 14-days (at the time of this writing) and individuals are allowed to isolate in their own homes, with their families and loved ones, making their treatment as means to an end far more digestible and outweighed by other ethical considerations.

The stigma associated with contracting HIV further compounds the ethical impermissibility of the sanitariums. Those who are HIV+ have historically faced discrimination and prejudice due to their health status, especially during the early years of the HIV pandemic; that have been portrayed as being inherently dangerous, threatening, sexually deviant and immoral individuals who partake in activities deemed “taboo” and unacceptable by their societies (i.e., same-sex relations, sex work, and injection drug use) (7). The sanitariums, by indefinitely segregating and isolating HIV+ patients from the rest of the population, are thus a physical representation and validation of this stigma and prejudice; had these patients in fact not been dangerous or immoral or partakers in taboo activities, they would not have contracted HIV and would not pose a threat to the population at large. As a result, the mandatory quarantines imposed by sanitariums are of far greater social significance than those implemented for COVID-19 patients.

The attitudes projected towards those who contract COVID-19 are far less discriminatory in nature, and do not tend to capitalize on already-existing prejudiced beliefs and bigotry (i.e., homophobia, misogyny, transphobia, shaming of sex work, etc.) experienced by minorities and vulnerable populations. While there may be negative perspectives of those who contract COVID-19, they are not stigmatized and demonized the way HIV+ patients have historically been. As a result, the implementation of mandatory quarantines for those with COVID-19 is not nearly as validating or confirming of any inherent “danger” or threat of “immorality” COVID-19 patients pose to the population at large. Their separation and quarantine remains for the purposes of eliminating the spread of a virus, and not in order to segregate specific demographics from the rest of the population on account of who they are or the activities they may partake in.

Furthermore, contributing to this dehumanization is the fact that it is not entirely clear that such strict quarantines were even required given the nature of HIV (as opposed to COVID-19) – as such, the sanitariums feel far more objectionable. Close contact between people does not guarantee transmission of HIV, it does not spread through air, and there is no clear evidence (even at the time) that those who share a household are automatically at risk (8). All these things, however, are true to varying degrees for COVID-19, making it far more justifiable that those who are infectious are required to isolate in order to reduce the risk of harm to others. Consequently, the impermissibility of the sanitariums is heightened even further with the silver bullet that such quarantine measures may not have been necessary in containing the HIV epidemic in Cuba.

Thus, in times of such crises and public health emergencies, it is surely in our best interests to implement measures that ensure the greatest amount of good for the greatest number of people, while simultaneously promoting beneficence, non-maleficence, and justice for the general populace, even if doing so comes at minimal infringements upon a smaller number of people’s autonomy. As such, mandatory quarantines, generally and in and of themselves, are not problematic – though the contextual elements of their implementation and the epi/pandemic may render them ethically impermissible.

 

References

  1. Public Health Agency of Canada. (2020, September 14). Coronavirus disease (COVID-19): Prevention and risks. Government of Canada. https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/prevention-risks.html

  2. Ontario Ministry of Health. (2021, January 12). Public health and safety measures in the provincewide shutdown. Government of Ontario. https://www.ontario.ca/page/enhancing-public-health-and-workplace-safety-measures-provincewide-shutdown

  3. Giubilini, A., Douglas, T., Maslen, H., & Savulescu, J. (2018). Quarantine, isolation and the duty of easy rescue in public health. Developing World Bioethics, 18(2), 182–189. https://doi.org/10.1111/dewb.12165

  4. Spitale, G. (2020). COVID-19 and the ethics of quarantine: A lesson from the Eyam plague. Medicine, Health Care and Philosophy, 23(4), 603–609. https://doi.org/10.1007/s11019-020-09971-2

  5. Mykhalovskiy, E., Cécile, K., Foreman-Mackey, A., McClelland, A., Peck, R., Hastings, C., & Elliott, R. (2020). Human rights, public health and COVID-19 in Canada. Canadian Journal of Public Health, 111(6), 975–979. http://dx.doi.org.myaccess.library.utoronto.ca/10.17269/s41997-020-00408-0

  6. Jeffrey, D. I. (2020). Relational ethical approaches to the COVID-19 pandemic. Journal of Medical Ethics, 46(8), 495–498. https://doi.org/10.1136/medethics-2020-106264

  7. Anderson, T. (2009). HIV/AIDS in Cuba: A Rights-Based Analysis. Health and Human Rights, 11(1), 93–104. https://doi.org/10.2307/40285221

  8. de Arazoza, H., Joanes, J., Lounes, R., Legeai, C., Clémençon, S., Pérez, J., & Auvert, B. (2007). The HIV/AIDS epidemic in Cuba: Description and tentative explanation of its low HIV prevalence. BMC Infectious Diseases, 7, 130. https://doi.org/10.1186/1471-2334-7-130


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