10 years ago

What looks like political wrangling or confusion in federal and state officials’ Ebola responses is a reflection of our complex public health system, which gives certain authorities to the federal government and others to the states. But however explainable as a product of American federalism, officials’ contradictory actions do little to reassure the public in a fast-changing environment where, here in the U.S., fear is as much an enemy as the virus itself.

There are more than 10,000 cases of Ebola in West Africa, where it remains an urgent public health emergency, but only four cases diagnosed in the U.S. to date. Yet 24-hour news coverage of debate over quarantines and isolation, travel restrictions, and other efforts has heightened tensions. In recent days we’ve seen Govs. Chris Christie and Andrew Cuomo institute quarantine and isolation measures before apparently backing off. Several states have announced their own policies. On Tuesday President Barack Obama rejected the idea of quarantining medical workers who return to the U.S. Yet on Wednesday, the Pentagon approved a 21-day monitoring period for all military personnel returning from west Africa.

Federal authority to quarantine and isolate derives from the Constitution’s Commerce Clause. The Public Health Service Act of 1944 authorizes the secretary of health and human services to “prevent the introduction, transmission, or spread of all communicable diseases from foreign countries into the States or possessions, or from one State or possession into any other State or possession.” HHS delegated this authority to the Centers for Disease Control and Prevention in 2000. This means that the federal government has quarantine and isolation authority in cases where someone is traveling to the U.S. from another country or traveling between the states. It can, however, only be applied to address a communicable disease specifically listed by presidential executive order. Executive order No. 13295 lists these diseases, including “viral hemorrhagic fevers,” of which Ebola is one, added in 1983.

But like many other laws and regulations–including gun laws and speed limits–all quarantine and isolation authority within a state rests with the state. Such laws vary across the country; thus the patchwork of Ebola pronouncements by governors. The federal government can make recommendations and provide guidance, support, and funding, but it cannot supersede state authority except in specific cases and, historically, has rarely done so.

There is a murky middle to our multi-layered approach to public health, with an evolving and sometimes confusing mix of guidelines across local, state and federal government. It’s not just that several states have announced Ebola policies. The just-announced U.S. military policy of controlled 21-day monitoring for personnel returning from West Africa appears to differ from the CDC guidelines calling for different levels of monitoring based on risk.

Having multiple public health standards across the country for a virus that doesn’t care about state borders arguably isn’t good public health policy. Different standards in different states are not only likely to confuse people but could suggest that we don’t really know how to respond or, worse, that there might be an element of political positioning to the response. Americans value states’ rights to make decisions about many things, and our system of public health gives states leeway to tailor responses to their own circumstances. But when it comes to Ebola in the U.S. the enemy now is fear as much as the virus; a uniform response led by national public health professionals would reduce fears.