Is Christie Calling the Shots When It Comes to NJ’s Quarantine Policies?

Andrew Kitchenman | October 28, 2014 | Health Care
The state has quarantine guidelines in place, did the administration follow them?

Credit: Kaci Hickox via CNN
Nurse Kaci Hickox spent three days in this tent after being quarantined for treating Ebola patients in Sierra Leone.
Kaci Hickox went home to Maine yesterday, after spending three days in a tent outside of University Hospital in Newark, quarantined because as a nurse she had treated Ebola patients in Sierra Leone.

Now public-health and legal advocates are questioning whether the state followed its own quarantine guidelines in how it treated her.

What makes those questions so tough to answer is that the quarantine policy at this point is pretty much what Gov. Chris Christie says it is. The only details about how it’s being implemented, what standards are being used, and who is being informed have to be gleaned from what Christie says publicly.

That helps explain the confusion about whether Christie had backpedaled on when he decided to let Hickox, who spent her quarantine without a shower or a flushable toilet, return home.

On Saturday, state officials said Hickox would remain under mandatory quarantine for 21 days and would be closely monitored by public-health officials. Yesterday, Christie rejected the idea that he had reversed his decision by allowing Hickox to leave, saying that she would stay in a hospital if she had symptoms.

The administration was less than forthcoming when NJ Spotlight submitted a series of questions regarding the details of the quarantine policy, only indicating that it was not prepared to answer a part of one of the questions. Other than that, it supplied copies of Christie’s comments from yesterday, announcing that Hickox had been discharged and saying that how the quarantine services would be paid for would be disclosed at a later time.

The administration’s unwillingness to answer questions has not satisfied public health advocates like Dr. Drew Harris, the director of the master of health policy program at Thomas Jefferson University in Philadelphia.

“It would seem that taking an otherwise healthy healthcare worker and placing her in an isolation tent to enforce a quarantine is not the least restrictive means necessary,” said Harris. “There are other ways to ensure that she doesn’t come into contact with other people, without having to put her into that kind of austere situation.”

Harris’s comment about the “least restrictive means necessary” refers to the quarantine policy that New Jersey already has on the books, the 2005 Emergency Health Powers Act — which, as its name suggests, comes into force when a state of emergency has been declared.

The law requires the state to seek a quarantine in Superior Court or, if a delay would jeopardize the public, that the state health commissioner issue an order stating the identity of those quarantined, where they will be quarantined, the time when the quarantine will start, and that a hearing to contest the order is available. Under the law, a copy of the order must be given to those affected by the quarantine.

However, since Christie hasn’t declared an emergency regarding Ebola, it appears that law’s quarantine guidelines aren’t in effect.

Credit: Kaci Hickox via CNN
The tent that Hickox spent three days in did not have a shower -- or a flushable toilet.
But Harris argues that it’s logical that Christie can’t go beyond what the law allows in a nonemergency. He’s concerned that the administration is reacting to public fear about Ebola, rather than decades of experience that medical experts have had treating the disease in Africa.

“I believe that we are making policy not on sound science but on speculation,” Harris said, noting that the virus is only spread when patients have symptoms, while Christie’s quarantine applies to all healthcare workers who had direct contact with Ebola patients.

“Is this really a case of the government crying wolf? And what’s going to happen when we actually do need a quarantine and people become numb to the idea?” he asked.

“The power of the government to restrict someone’s freedom should be used rarely and with great care and only as a last resort and not as first resort. They basically said to this woman, ‘We don’t trust you when you say that you’re not going to expose others, or when you say that you’re not sick’ and I think that’s a bit too much.”

Hickox said her treatment, including a three-hour period in which she was isolated at the airport and no one spoke with her, as “inhumane.”

Christie said yesterday that Hickox was treated “quite well in New Jersey” and that the quarantine was based on his obligation to protect the public.

“You worry about doing what’s right for the people you represent and that’s what we’ve done,” Christie said at a campaign stop in Florida yesterday, where he was travelling with Gov. Rick Scott.

Christie emphasized that Hickox had run a fever, according to a forehead scanner that indicated a high temperature. She said her face was flushed after several hours of detention and questioning. A later, more accurate reading with an oral thermometer found that her temperature was normal.

“If you live outside the state and you’re symptomatic, we’re not letting you go onto public transportation,” Christie said. “It makes no common sense. The minute she was no longer symptomatic, she was released.”

Under the quarantine, healthcare workers who live in New Jersey who had direct contact with Ebola patients in Africa would be required to stay in their homes for 21 days, while those who live outside the state and don’t have symptoms would be transported to their homes. But those who do have a fever or other symptoms would be taken to a hospital in New Jersey.

“It’s the policy that has been instituted since (Friday) that dealt with the woman from Maine and will deal with anybody else who is a healthcare worker who has direct contact with someone who has the Ebola virus. There has been no change. No difference,” Christie said.

On Sunday, New York Gov. Andrew Cuomo apparently reversed his position on the quarantine. While he said on Friday that healthcare workers who had direct contact with Ebola patients would be quarantined in “government-regulated facilities,” he modified that position by saying they could stay in their homes.

Cuomo said the policy wasn’t a change, but merely provided details for the policy outline he provided on Friday.

The federal Centers for Disease Control and Prevention released new, non-mandatory guidelines to states, which require those who had direct contact with Ebola patients to have daily checkups with local or state healthcare providers. While the federal officials hoped to bring uniformity with the new guidelines, New Jersey has taken a more aggressive position.

The American Civil Liberties Union of New Jersey filed an open-records request yesterday, asking for details on the procedures the state is using to implement the quarantine.

“It is essential that the state of New Jersey be as clear and transparent as possible about the scientific information and health policy thinking that is being relied upon to formulate protocols and policies, especially when the public policy is as drastic as a 21-day quarantine,” executive director Udi Ofer said in a statement. “ The public needs to be reassured that these policy decisions are being guided by science, not fear.”

National ACLU board member Frank Askin, a constitutional rights professor at Rutgers-Newark School of Law, said he was “surprised that Christie backed down” in releasing Hickox.

“He doesn’t usually,” Askin said. “Politicians shouldn’t be making these decisions. It’s up to health professionals to decide. The state has to have a good reason to hold someone against their wishes for 21 days.”

Askin said other healthcare workers filing legal challenges to quarantines would face difficulties .

“This is going to be hard on judges — they’re going to be very scared of these cases,” he said. “They don’t want to let someone out and (then) they’re going to spread the disease.”

Askin expects that the federal and state guidelines will ultimately be aligned.

“It will probably take another week or so to take everybody on the same page,” he said. “Right now people are flying by the seat of their pants because this came on very suddenly.”

Adding to the confusion, the state provides municipalities with a set of quarantine guidelines that are similar to those in the Emergency Health Powers Act.

Seton Hall health law professor John V. Jacobi said there would be advantages to the state following these existing quarantine guidelines it provides to local towns, since they’re based on court precedents that balance residents’ legal rights with public-health concerns. The guidelines set out a procedure for those who have been quarantine to file a legal challenge to the quarantine order.

While a government body arguing in court for a quarantine “has to satisfy the judge with clear and convincing evidence … it’s clear that judges will accord some deference to public health agencies, as they should,” he said.

While Jacobi said there were clear cases where quarantines in hospitals are necessary, he wasn’t in a position to comment on Hickox’s case because he didn’t know the details.

“It is clear that if you’re going to be isolating someone, you have to do so in a way that accommodates their interests and their comfort as much as possible,” he said. “I don’t mean to minimize the state’s interest to protect the public health — that is something that any judge would take seriously, but the judge would be balancing it to make sure that (a quarantine is) no more restrictive than necessary and that it’s justified under the facts.”

Harris said the recent public reaction to Ebola reminded him of the 1980s.

“I’m having déjà vu over the hysteria regarding AIDS, as to whether you can catch AIDS from toilet seats,” Harris said, adding of Ebola: “You really need a higher level of contact — that just doesn’t happen when you’re on a subway or on a bowling alley.”

Harris said he hoped that the next healthcare worker arriving from Africa wouldn’t face the same experience as Hickox.

“I would imagine the next person wouldn’t be subject that to that kind of confusion and chaos,” he said. “They’ll figure out — at least I hope they will — everyone is entitled to due process. They need to know what the procedures are.”

Harris also said clearly telling the public about the medical evidence for allowing healthcare workers to monitor themselves would increase public understanding of Ebola.

“There’s a danger that in giving in to people’s fears, you validate the fears instead of using this as a moment to educate people on the disease, and to what we know about the disease and bring them around to where the facts are as to opposed to what their fears are,” he said.

However, public trust in federal health authorities may have been undermined by the cases of two nurses in Dallas who contracted the Ebola virus despite taking precautions.

A Fairleigh Dickinson Public Mind poll released yesterday found that 53 percent of state residents are more optimistic that the state can do a better job of handling Ebola than the feds, while 66 percent of residents rated the federal government’s response to the cases in the United States as fair or poor. The poll was taken in mid-October, before the quarantine.