Quarantine for all

With no vaccine or effective treatment for COVID-19, social distancing measures such as quarantine take on greater importance. To be most effective, the quarantine compliance rate should be 90 percent, which means that virtually all individuals selected for quarantine should take part.

Even under the best of conditions, with palatable food, necessary supplies, and medicines for other medical conditions, quarantine is difficult because individuals feel well but have limited contact with their family and friends.

There is also a high level of stress in not knowing whether the next temperature check or medical test will be positive and initiate a life-threatening illness. When faced with a lack of income or a fear of being fired, deported, or imprisoned, quarantine can be a nightmare.

Numerous employers are adopting the CDC guidelines calling for flexible work environments and liberal absentee policies, but many Americans fear they will be fired from their jobs if they fail to show up for work.

Most state laws allow employers to discharge employees without a contract of employment for any reason, including absence from work. Only 10 states have laws prohibiting employers from discriminating against individuals in quarantine. Iowa provides for reinstatement, and Massachusetts, Minnesota, and New Jersey allow employees to recover lost wages.

Every state should enact a broadly protective law banning employers from discriminating against workers in quarantine. While the decisions to impose a quarantine are typically made by salaried government and public health officials — it is the lower-wage and hourly employees, as well as those who are self-employed, who have the most to lose economically. Loss of income is a frequently cited obstacle to quarantine compliance.

In the U.S., millions of Americans lack paid sick leave. Many of these individuals work at jobs that cannot be done remotely, such as those in the face-to-face service industry or those who work in the gig economy. Without paid sick leave or some form of compensation, asymptomatic individuals may go to work, disregarding a quarantine order or recommendation. Only one state, Massachusetts, provides any income support for people in quarantine, a grand total of $2 for every working day, pursuant to a law enacted in 1907.

The lack of measures to limit the economic insecurities resulting from quarantine in the U.S. contrasts with laws in other countries prohibiting employment discrimination against individuals in quarantine, providing paid sick leave, and compensating quarantined individuals. These laws have been considered keys to success in containing the spread of past communicable diseases. 

For example, during the SARS epidemic in 2003, Canada, China, Hong Kong, Singapore, and Taiwan enacted laws to compensate individuals for lost wages or other economic harm attributable to the epidemic. Even modest proposals for compensation are only now being considered.

Fears of loss of income increase when individuals face possible medical expenses associated with the outbreak. Although insurers are now waiving cost-sharing for COVID-19 testing, the economic insecurity surrounding this outbreak is real. There are 27.9 million uninsured Americans, and millions more who are underinsured or have prohibitively high deductibles.

Even before the outbreak, 16 percent of Americans reported having medical debt in collections. In May 2019, the Federal Reserve issued its Report on the Economic Well-Being of U.S. Households, which found 24 percent of adults skipped medical care because they were unable to afford the cost and approximately 39 percent of individuals faced with an unexpected expense of $400 would have difficulty or would not be able to cover the expense. In the context of the COVID-19 outbreak, these individuals may be less likely to seek professional care if they become exposed and fear associated medical expenses and loss of income. 

Finally, many vulnerable individuals, including undocumented immigrants, may avoid quarantine in government facilities or in locations known by the government because they don’t want any contact with the government. According to the Pew Center for Research, 10.5 million undocumented immigrants are living in the U.S. The fear of arrest and deportation associated with seeking treatment or entering quarantine could drive people underground which could not only harm them but endanger the health of the entire population.

Other groups, such as runaway youth, AWOL soldiers, and criminal fugitives, may also avoid quarantine orders or recommendations. To be effective, the quarantine must include all potentially exposed individuals, and to obtain their compliance there must be legitimate and clear policies that individuals voluntarily entering quarantine will not be arrested or deported. 

The COVID-19 public health crisis has exposed other gaps in our public health system that legislators and public health officials should address to ensure that vulnerable populations will comply with social distancing measures. These include providing individuals with substance use disorders assurances of effective drug treatment while in quarantine, providing adequate shelter and medical treatment to transient and homeless people who may be exposed to COVID-19, and arranging care for dependent children, adults, and pets when caregivers enter quarantine.

Many of these actions may be politically unpopular, but individuals in quarantine make a sacrifice that benefits all of society. Implementing policies to promote compliance and contain the spread of disease is both a moral imperative and a public health necessity.  The COVID-19 outbreak is a challenge to enact measures that promote public health while protecting the most vulnerable, and to demonstrate the altruism and compassion that epitomize our society’s highest ideals. 

Mark A. Rothstein is the Herbert F. Boehl Chair of Law and Medicine and Director of the Institute for Bioethics, Health Policy and Law, University of Louisville School of Medicine. Christine N. Coughlin is a Professor of Legal Writing at Wake Forest University School of Law, and a core faculty member in the Wake Forest University Center for Bioethics, Health & Society.