How the Ebola quarantine became a ‘states’ rights’ issue
What if someone with a deadly and mysterious infectious disease arrived at one of the largest urban centers in the United States? Certainly, we would expect the White House to consult the finest scientific minds in the federal government, academia and medicine to develop the best, most evidence-based approach to the contagious crisis.
But what if the governor of the state where this metropolis is located disagrees with the president? And because he knows that U.S. law gives individual states the authority, he demands his own version of quarantine? Add to this quagmire a heated, almost panic-stricken, environment where everyone, from the media to John Q. Public, is demanding that the president and his corps of public health officials do something to end this nightmare.
No, I’m not talking about the current Ebola crisis. Or New Jersey Governor Chris Christie’s ill-advised move to quarantine a nurse, Kaci Hickox, in a tent because she had just returned from a heroic stint in Sierra Leone treating Ebola patients. Instead, we need to go back to the fall of 1892. The president was Benjamin Harrison. The chilling infection was “Asiatic cholera,” which had stalked the globe three times before in the 19th century to deadly effect.
What remains frustrating about how the United States manages epidemics — as we are rediscovering with the Ebola crisis — are the hazy lines of authority and fierce internecine battles among local, state and federal health agencies, as well as individual hospitals and healthcare systems. Equally discouraging are the distracting criticisms of health officials, doctors and nurses trying to do a complicated job under difficult conditions while subjected to intense media scrutiny.
Let me illustrate these public health dilemmas with some history.
Through much of the summer of 1892, cholera devastated much of Eastern Europe and shut down the port of Hamburg, Germany. By summer’s end, New York City, the largest port in the United States, where 75 percent of all immigrants landed, began receiving its first cholera victims — mostly impoverished Russian Jews traveling by steerage in a dozen or more Hamburg-American steamships.
Harrison, in the middle of a reelection campaign, avoided the charged issue of states’ rights with respect to control over public health matters. This “right,” which can now only be described as a legal “wrong,” emerged in an era when doctors subscribed to the “miasma doctrine of epidemics.”
The best medical minds then taught that rotting organic material — such as sewage, garbage and even animal carcasses — gave off foul emanations that polluted the atmosphere and started local epidemics. Hence, the health of New York City was dependent upon its local miasma situation, considered to be different from the health status of, say, Newark, New Jersey.
Harrison initially encouraged individual states to develop their own containment protocols, including the quarantine of all immigrants for so long that it was too expensive for the shipping companies to bear.
But he also realized there would be too little uniformity. So on Sept. 1, after consulting with his surgeon general, Walter Wyman, and a slew of other doctors, the president buttressed this arrangement by mandating an additional 20-day quarantine.
Sadly, Harrison failed to pay close attention when his experts advised him that cholera germs were exquisitely egalitarian in their mode of attack. So he ordered the quarantine only for steerage-class immigrants — mostly “undesirable” East European Jews fleeing the violent tyranny of czarist Russia — but not for those traveling in the high-priced cabin class. Harrison’s bigotry trumped his allegiance to science as he described these Russian Jews in his executive order as a “direct menace to the public health.”
One lone editorial writer for the old New York Tribune did challenge “the Little General,” as Harrison was nicknamed because of his Civil War service: “The mere fact that a traveler is able to pay for a cabin passage should be held to indicate that he has a charmed life and is incapable of transmitting contagious diseases passes comprehension.”
For the most part, however, the federal government’s preferential treatment of cabin-class passengers from the same cholera-infected ports elicited relatively few complaints in the American press or among the public at large.
On the first day of the detentions, the quarantine officer of the Port of New York, William Jenkins, who had been appointed by the powerful Tammany Hall Democratic machine, reacted with hostility to the Republican president’s policy. Jenkins gave a bellow that was supposedly heard “from Quarantine to the Battery.” It was the direct opposite of the Christie debacle this past weekend, in that the New Jersey governor wanted more quarantine stringency and the federal government wanted less.
Jenkins, like Christie, insisted that he was in charge of all health issues on his turf and challenged Harrison’s executive order. The dramatic illustration of this confrontation between state and federal rights culminated with the steamship SS City of Berlin, which carried steerage as well as cabin-class passengers from cholera-ridden Hamburg, sent back and forth between the quarantine station and the U.S. port collector’s cutter, as each official refused to recognize the other’s authority.
Jenkins finally backed down after a midnight meeting with his canny brother-in-law, Tammany Boss Richard Croker. It was “neither wise judgment nor good politics,” Croker advised, to mess with the president of the United States.
Throughout September 1892, many more cases of cholera came into New York harbor. Thousands of passengers, immigrants from steerage and cabin-class passengers, were quarantined. The former were housed in wretched facilities on Hoffman Island, where some 44 immigrants died of cholera. The cabin-class passengers were taken to a swank hotel on Fire Island, much to the consternation of the local residents. An angry mob was quelled only after the governor ordered in two National Guard units and two Navel Reserve units.
Another nine cholera deaths occurred in New York City itself, 44 died at the New York Quarantine Station and 76 passengers died en route before the epidemic burned itself out. This number, incidentally, was miniscule compared to the tens of thousands of deaths occurring simultaneously in Europe.
Though Harrison lost his reelection bid that November, in February 1893, his executive order evolved into the National Quarantine Act of 1893. It gives the president the power to contain an epidemic crisis — a power that has not been invoked since that long ago fall of 1892.
Did the 20-day quarantine work? It was probably helpful since it significantly reduced the flow of immigrants and the overwhelming workload of medical inspection. So, too, did the medical and public health management of the crisis in New York City, bolstered by advance notice of the Hamburg epidemic and those ships most likely to carry cholera, as well as the long travel time across the Atlantic Ocean — a luxury that jet planes have made obsolete.
But there were also huge costs, such as the scapegoating of all East European immigrants as cholera vectors, not to mention the public’s condemnation of all the health officials trying to stem the tide of the epidemic, no matter which tack they took. The overflowing quarantine station near Staten Island — and other stations like it across the nation — was neither upgraded nor staffed with enough doctors, a perennial problem that hindered the epidemics that followed.
More troubling, many of the shortcomings in epidemic preparedness and management discovered during the 1892 crisis remained long after the cholera faded into memory and Harrison lost his presidency to a resurgent Grover Cleveland.
Sadly, history teaches us that once the Ebola crisis subsides, we will likely revert to the same practices and conditions that gave rise to the epidemic in the first place. The time has come to change this oppressive historical pattern by refusing to succumb to the epidemic amnesia of our predecessors.
That means U.S. political leaders need to develop and enact a uniform and acceptable set of guidelines, with clear lines of authority of who is in charge during a contagious calamity. Such a plan must acknowledge that if deadly germs do not respect state borders, neither can our legal framework for dealing with them.
Moreover, once the United States gets its own Ebola threat in check here at home, we must commit to a major effort to contain and defeat the virus where it is exploding: West Africa.
How many times do Americans have to be reminded that obliviousness to epidemic disease anywhere on the planet can be extremely hazardous to our collective health back home?
PHOTO (TOP): New Jersey Governor Chris Christie speaks during a news conference about New York’s first case of Ebola, in New York, October 24, 2014. REUTERS/Carlo Allegri
PHOTO (INSERT 1): President Benjamin Harrison, official White House portrait painted by Eastman Johnson. WIKIPEDIA/Commons
PHOTO (INSERT 2): Immigrants from a smallpox ship, held in custody for observation, behind wire fence on Hoffman Island, New York, May 23, 1901. REUTERS/Library of Congress
PHOTO (INSERT 3): Physicians examining a group of Jewish immigrants on Ellis Island. REUTERS/Library of Congress
PHOTO (INSERT 4): Emigrants coming up the board-walk from the barge, which has taken them off the steamship company’s docks, and transported them to Ellis Island in 1902 REUTERS/Library of Congress
PHOTO (INSERT 5): Navy Commander (Dr.) James Lawler (C), an infectious disease physician, talks to team members during a training event at the San Antonio Military Medical Center on Joint Base San Antonio-Fort Sam Houston, Texas, October 25, 2014. REUTERS/Department of Defense/Army Sgt. 1st Class Tyrone C. Marshall Jr./Handout via Reuters