First word

IMAGINE how much more clarity and direction there would have been in the nation’s pandemic response had the unelected and unelectable Inter-Agency Task Force for the Management of Emerging Infectious Diseases (IATF-EID) not juggled the concepts of lockdown and quarantine as though they were identical with each other.

Imagine also how much more thoughtful the task force would have been in its policy diktats had its members known about the story of Draco the lawgiver and his fate in ancient history.

Had these hypotheticals happened, we would not be in this quizzical situation today where the acronyms — GCQ, ECQ, MECQ — look more like headstones for the nation’s pandemic response, rather than the promised signposts to national deliverance from the pandemic.

A quick digression into Draco’s curious story is apposite, because it is cautionary and instructive.

Draco and his laws

According to the Encyclopedia Britannica, Draco, who lived in 7th century BC, was an Athenian lawgiver whose harsh legal code punished both trivial and serious crimes in Athens with death.

Draco gave Athens its first comprehensive lawcode (perhaps 621). Because of the code’s extreme harshness, Draco’s name has become a synonym for legal savagery.

Aristotle, the chief source for knowledge of Draco, claims that his were the first written Athenian laws. Draco was the first democratic legislator requested by the Athenian citizens to be a lawgiver for the city-state, but the citizens had not expected that Draco would establish laws characterized by harshness.

Little is known about Draco’s life. He may have belonged to the Greek nobility of Attica prior to the period of the Seven Sages of Greece, as per the 10th-century Byzantine encyclopedia, the Suda. The Suda chronicles a folkloric story of his death in the Aeginetan theater. The truth about his death is still unclear, but it is known that Draco was driven out of Athens by the Athenians to the neighboring island of Aegina, where he spent the remainder of his life.

All of Draco’s laws were repealed by Solon in the early 6th century BC, with the exception of the homicide law.

Lockdown and quarantine

When the Duterte government announced its community quarantine strategy to control the pandemic, the IATF-EID declared that a community quarantine was equivalent to a lockdown, which the Chinese government had already imposed in the city of Wuhan in Hubei province where the viral outbreak began.

Thereafter government communicators thought using CQ as a euphemism for a lockdown was a neat way to disguise a harsh policy. And then the IATF-EID piled up the acronyms — GCQ, etc. — one on top of the other, so much so that the government got buried in its own propaganda. It lost track of the precise meanings and distinction between a lockdown and a quarantine.

For the whole year of 2020, the government never thought of lifting the community quarantine. In this way, the country plunged headlong into the longest lockdown in the world, which has done nothing to even slow down the pandemic in the country

Juggling the terms lockdown and quarantine was neither sensible nor sound for public health policy?

Many thinking people believe that the juggling practice served to muddle the country’s pandemic response, and rendered each tool toothless in the emergency.

Lockdown

A lockdown is a restriction policy for people or community to stay where they are, usually due to specific risks to themselves or to others if they can move and interact freely. The term “stay-at-home” or “shelter-in-place” is often used for lockdowns that affect an area, rather than specific locations.

The term is used for a prison protocol that usually prevents people, information or objects from leaving an area. The protocol can usually only be initiated by someone in a position of authority.

A lockdown can also be used to protect people inside a facility or, for example, a computing system, from a threat or other external event. In buildings doors leading outside are usually locked so that no person may enter or exit. A full lockdown usually means that people must stay where they are and may not enter or exit a building or rooms within it, needing to go to the nearest place designated safe if not already in such a place.

A preventive lockdown is a preemptive action plan implemented to address an unusual scenario or a weakness in system to preempt any danger to ensure the safety and security of people, organization and system. The focus for preventive actions is to avoid dangers and risks arising from the non-conformances with the normal circumstances, but also commonly includes improvements in efficiency.

Preventive lockdowns are preemptive lockdowns to mitigate risk. Most organizations plan for the emergency lockdowns but fail to plan for other situations that might quickly degrade to dangerous levels. These protocols must be based on the type of threat, and should be kept simple and short for quick learning and implementation, and flexible enough to handle several scenarios.

Emergency lockdowns are implemented when there is imminent threat to the lives or risk of injury to humans, for example, a school’s emergency lockdown procedures must be kept short and simple to make them easier to use under real life crisis conditions.

In epidemics and pandemics, lockdowns limit movements or activities in a community while allowing most organizations to function normally, or limit movements or activities such that only organizations supplying basic needs and services can function normally.

Quarantine

A quarantine is a restriction on the movement of people, animals and goods which is intended to prevent the spread of disease or pests. It is often used in connection to disease and illness, preventing the movement of those who may have been exposed to a communicable disease, yet do not have a confirmed medical diagnosis. It is distinct from medical isolation, in which those confirmed to be infected with a communicable disease are isolated from the healthy population. Quarantine considerations are often one aspect of border control.

The concept of quarantine has been known since biblical times and is known to have been practised through history in various places. Notable quarantines in modern history include the village of Eyam in 1665 during the Bubonic Plague outbreak in England; East Samoa during the 1918 Flu Pandemic; the Diphtheria outbreak during the 1925 Serum Run to Nome, the 1972 Yugoslav Smallpox Outbreak, and extensive quarantines applied throughout the world during the coronavirus pandemic since 2020.

Ethical and practical considerations need to be considered when applying quarantine to people. Practice differs from country to country; in some countries, quarantine is just one of many measures governed by legislation relating to the broader concept of biosecurity.

What is different about the 2020 health emergency is that the quarantine is being used by governments for the first time as a key strategy to stop the pandemic.

Mass quarantine

In the pandemic, China used both lockdown and mass quarantine to control the viral outbreak. After a costly delay in reporting the outbreak, China locked down Wuhan and the wider Hubei province, confining about 60 million people, the largest cordon sanitaire (a guarded area where no one can enter or leave) in human history. Its draconian measures were medieval, but they elicited praise from the World Health Organization (WHO). In late February 2020, the WHO-China Joint Mission on Coronavirus Disease 2019 concluded that the cordon sanitaire was effective, with Director-General Tedros Adhanom Ghebreyesus urging all countries to learn from the China model.

The joint mission did not present clear evidence, however, on why or how the measure was effective. WHO appeared to shift its policy of defending freedom of movement, trade and travel, as well as human rights, towards protecting public health as the overriding utilitarian consideration.

This does not change the fact that quarantines are a blunt tool, sweeping up many people who pose no risk to the public. Even under a declared public health emergency, it is not likely that the courts would uphold such a far-reaching restriction of liberty.

Under any ethical tradition, well-designed, evidence-based quarantines are permissible.

Individuals have freedom of movement only until they pose a significant risk to others. If an individualized risk assessment finds a person has been exposed to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), it is ethical to keep that person separated from the public for the longest period of incubation (14 days). But liberty is too important to act on the basis of group determinations. That is, if SARS-Cov-2 were circulating among a large population, we would have scant evidence that all, or even most, individuals were a risk to the public. The better course is less restrictive measures such as screening and contact tracing, and social distancing such as temporary closures of crowded places, like schools, mass transit, and sporting, entertainment and political gatherings.

As one medical professional wrote in the Canadian Journal of Public Health, “Justification of quarantine and quarantine laws stems from a general moral obligation to prevent harm to others if this can be done. Most democracies have public health laws that permit quarantine. Even though quarantine is a curtailment of civil liberties, it can be broadly justified if several criteria can be met.”

He cited four such principles:

“First, the harm principle must be met. In other words, there should be clear and measurable harm to others should a disease or exposure go unchecked. For quarantine, this infection should be spread from person to person. In diseases that are infectious but cannot be spread from person to person, such as anthrax, quarantine cannot be justified.

“Secondly, the proportionality, or least-restrictive-means, principle should be observed.

This holds that public health authorities should use the least restrictive measures proportional to the goal of achieving disease control. This would indicate that quarantine be made voluntary before more restrictive means and sanctions such as mandatory orders or surveillance devices, home cameras, bracelets, or incarceration are contemplated. It is striking to note that in the Canadian SARS outbreak in the Greater Toronto area, approximately 30,000 persons were quarantined at some time. Toronto Public Health reports writing only 22 orders for mandatory detainment. Even if the report is a tenfold underestimate, the remaining instances of voluntary quarantine constitute an impressive display of civic-mindedness.

“Thirdly, reciprocity must be upheld. If society asks individuals to curtail their liberties for the good of others, society has a reciprocal obligation to assist them in the discharge of their obligations. That means providing individuals with adequate food and shelter and psychological support, accommodating them in their workplaces, and not discriminating against them. They should suffer no penalty on account of discharging their obligations to society.

“Finally, there is the transparency principle. This holds that public health authorities have an obligation to communicate clearly the justification for their actions and allow for a process of appeal. If the above conditions can be met, there is a prima facie justification for the use of quarantine.”

In summary, quarantine is a blunt instrument to use in the control of infectious diseases. However, in some circumstances it is one of the only possible means of responding to an infectious disease threat.

Even then, public health professionals must continually update their information in order to refine the exposure criteria, so that people are not needlessly quarantined.

“Epidemics have a way of bringing out the best and worst in society. Each of us should take care not to infect family, neighbors, and community. We will need to show kindness toward our neighbors who are elderly and vulnerable. We also need to bring the best out in our political leaders. And pull together to ensure that all of society is cared for. No one should be fearful, alone, or neglected,” says Lawrence Gostin, a United States law professor who specializes in public health law.

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