In 1988, the WHO established a partnership to combat river blindness in West Africa.  This partnership was more recently was expanded to include thirty endemic countries in Africa.[47]  In addition, the WHO launched the Global Polio Eradication Initiative in 1988 with the mission of eradicating transmission of wild poliovirus by the end of 2000.[48]  In 1997, the WHO initiated a program to combat meningitis and rabies.[49]  In 1999, the WHO began to target malaria and tuberculosis.[50]

The Importance of Public Health Protective, Preventive, and Containment Measures during the SARS Outbreak of 2002 and 2003

            Recently, individuals located not only in one geographic region but also around the world have contracted the relatively new and unknown disease known as Severe Acute Respiratory Syndrome (SARS).  The rapid spread of this highly contagious disease greatly taxed the public health systems of numerous states.  “As bacteria and viruses become resistant to anti-microbials and new emerging infections appear, it can be expected that personal restrictions and isolation will again be a core strategy in public health.”[51]  The outcomes of outbreak, which initiated in Asia and rapidly spread to neighboring countries and to over two dozen countries in four continents, perhaps were not as catastrophic as could have been because of specific public health measures including the use of quarantine and isolation.  Quarantine is a public health tool whereby individuals who have been in contact with infected individuals or localities are prohibited from activities outside a specified area for a specified time in order to ensure that the individual does not develop the disease and subsequently spread that disease to others.  Isolation is a tool in which infected individuals are isolated until the likelihood of spreading the disease to others has subsided.  The difference between quarantine and isolation is that with quarantine the movement of non-infected persons is restricted, whereas with isolation the movement of infected persons is restricted.  An individual in quarantine who contracts the disease will be moved to isolation.  Although these protective measures have been implemented for hundreds of years, these “[p]ersonal restrictions pose two legal problems: they violate an individual’s right of autonomy, and they can be an invasion of privacy to the extent that they must be publicly known.”[52]  As of mid-April 2003, 3,200 individuals had contracted SARS and 154 had died from this disease.  SARS did not come to the attention of the global public health scene until March 2003; however, the first known cases were identified as early as November 2002.  Due to the rapid spread of SARS around the world, the WHO issued its first-ever travel warning in early April 2003 advising individuals against traveling to Hong Kong and the Guangdong province unless absolutely essential.[53]  Between “November 1, 2002 and May 14, 2002, a total of 7,628 SARS cases were reported to the WHO from 29 countries” and “587 deaths . . . have been reported.”[54]  To understand why quarantine and isolation are effective public health tools that must be kept in the repertoire of methods for controlling the spread of disease, it is useful to analyze the impact of SARS on those states that were most severely impacted: China and Taiwan.  Additionally, a look at how the United States managed the SARS epidemic provides comparative data about the impact of quarantine and isolation. 

China: Between March and July of 2003, approximately 2,521 probable cases of SARS were reported.[55]  Consequently, an estimated 30,000 Beijing residents were quarantined in their homes or quarantine sites.  Initially, the Chinese Ministry of Health required quarantine to last for fourteen days for persons who met specified criteria for contact with a known SARS infected person.  The period was later reduced to ten days and subsequently to three days.[56]  Additionally, persons who entered Beijing with fevers greater than 100.4 degrees Fahrenheit and who arrived from SARS infected locations were also placed under quarantine.[57]  All persons who were placed under quarantine received daily visits from quarantine officers and were provided with necessities such as food and medicine.  If an individual contracted the disease then he/she was transferred from home quarantine to a hospital for isolation.[58]  The Chinese Center for Disease Control and Prevention (China CDC) conducted a survey to determine the efficacy of quarantine and to guide future policy decisions.  Within the Haidian District, 5,186 persons were quarantined at some point during March 1 through May 23.  After May 26, 1,210 residents were sampled with an eighty-five percent response rate.  Of these individuals, 232 acquired probable SARS during their quarantine period, and only individuals who had a history of contact with a SARS patient acquired SARS during the quarantine period.[59]  This survey is significant because it illustrates which populations are most likely to contract SARS and, therefore, should be placed under quarantine.  By “focusing only on persons who had contact with an actively ill SARS patient . . . the numbers of persons quarantined [would have been reduced] by approximately 66% . . . .”[60]  However, it is important to note that the survey conducted is subject to several limitations, including but not limited to the following: 1. It is an initial survey.  2. The survey was not representative of all persons quarantined.  3. It was subject to self-reported data.  4. The infection status of the participants was not based on clinical diagnosis.[61]

Taiwan: In Taiwan, 131,132 persons were placed under quarantine, of this 50,319 persons had close contacts with SARS patients and 80,813 were travelers from WHO-designated SARS-affected areas.[62]  The quarantine was extensive because “unrecognized cases of SARS led to nosocomial clusters and subsequent spread,” which “resulted in substantial morbidity and mortality and resulted in the closure of several large health-care facilities.”[63]  In Taiwan, quarantined persons were required to take their own temperature several times per day and to seek immediate medical care if any of the following symptoms were present: cough, fever, shortness of breath, and other respiratory symptoms.  Additionally, Taiwan quarantined persons on two levels that allowed varying degrees of activity outside of the quarantine site.  However, trips outdoors were recorded to ease in possible future investigations.[64]  As of yet, an analysis of the impact of quarantine and isolation has not been conducted in Taiwan.

United States: By May 14, 2003, 345 SARS cases were identified in the United States and reported from thirty-eight states.[65]  Sixty-four of these cases were classified as probable SARS which is more serious than suspect SARS.  Of these cases, approximately ninety-seven percent were attributable to international travel within ten days prior to onset of illness.[66]  The United States, in contrast to China and Taiwan, did not incur significant secondary spread and consequently did not utilize quarantine as a preventive measure; however, infected individuals were isolated.[67]  During the SARS outbreak in the United States, CDC quarantine officials:

§         Provided information about SARS to air travelers and to persons traveling via cargo and cruise ships who were arriving, directly or indirectly, from East Asia,

§         Distributed over 20,000 health notices advising travelers that they might have been exposed to SARS and how to monitor their health,

§         Assessed symptoms of individuals on airplanes to ensure they do not have SARS, and

§         Updated government agencies, and state and local health departments.[68]


“Public health is no longer the prerogative of physicians and epidemiologists.  International health law, which encompasses human rights, food safety, international trade law, environmental law, war and weapons, human reproduction, organ transplantation, as well as a wide range of biological, economic, and sociocultural determinants of health, now constitutes a core component of global communicable disease architecture.”[69]  Specific behaviors and related diseases disproportionately affect developing countries, which already have fragile health and social infrastructures.  For example, the increase of injecting drug users in developing countries presents threats of outbreaks of HIV and hepatitis C.[70]  To effectuate scientific solutions for global health threats, the international community must make a coordinated global response.  Dr. John Evans, Chairman of the Commission on Health Research for Development, aptly remarks in testimony before the United States House Appropriations Committee, “that with increased awareness of global interdependence in health, self-interest should reinforce humanitarian concerns’ in our efforts to improve global health.”[71]  One mechanism by which to achieve improved global health is to shift public health education from focusing primarily on research to preparing and enabling providers to implement appropriate public health practices.[72]  However, to effectively combat the spread of highly communicable diseases, especially those diseases which are new and the pathology of which is not yet understood or known, it is imperative for states to inform the international community of local public health problems.  The spread of SARS might have remained much more localized if China, the first state to see the disease, had informed the WHO and the international community of the unknown pathogen when the pathogen first appeared.  As previously stated, the first case of SARS was diagnosed in China in November of 2002; however, the international community did not become aware of the virus until March of 2003, at which point, the disease had already spread to many states and infected many persons.  Although detrimental economic effects might befall a state when that state reports an unknown and highly communicable disease to the international community, the economic effects will most likely be temporary and the international community will aid in addressing the disease and preventing further spread, and thus protecting the public health of many states.  “The international spread of disease underscores the need for strong global public health systems, robust health service infrastructures, and expertise that can be mobilized quickly across national boundaries to mirror disease movements.”[73]


[1]     Schambra, Dr. Philip E.  “Testimony on the Fogarty International Center’s FY 1998 Budget.”  Before the House Appropriations Committee, Subcommittee on Labor, Health and Human Services, Education and Related Agencies.  March 5, 1997.  Available at:  Accessed on: January 29, 2003.

[2]     Many of the issues discussed are to some extent reflected upon by international health organizations for the formulation of international governmental and organizational policies; however, this paper serves to illustrate the importance of incorporating these issues into the formulation of domestic public health policy to safeguard against threats and to ensure a healthy public.

[3]     See Gina Kolata, Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It, New York: Touchstone, 2001, for an interesting discussion of the flu pandemic of the early twentieth century.

[4]     Klare, Michael T.  “Redefining Security: The New Global Schisms.”  Current History.  November 1996: 353-358.  SIRS Database.

[5]     Basic Facts About the United Nations. New York: United Nations, 1998 (164).

[6]     GATT’s restriction has one exception: trade restrictions can be used to enforce public health law only if the state can show that the state is using the least trade restrictive policy possible.  Breslow, Marc.  “How Free Trade Fails: How GATT & NAFTA harm democracy, ecology, & the Third World.”  Dollars and Sense.  October 1992: 6-9.  SIRS Database.

[7]     Aginam, Obijiofor.  “International Law and Communicable Diseases.”  Bulletin of the World Health Organization 2002.  Available at:  Accessed on: February 5, 2003.

[8]     Bankowski, Zbigniew.  “Ethics and Health.”  World Health.  April 1989: 2-6.  SIRS Database.

[9]     Id.

[10]   “AIDS Pandemic: Global Scourge, U.S. Challenge.”  Great Decisions.  New York: Foreign Policy Association.  1992: 69-78.  SIRS Database.

[11]   Foster, Harold D.  “Reducing the Incidence of Disease – Clues from the Environment.”  Environment.  April 1989, Volume 31, Number 3.  Published by Heldref Publications.  SIRS Database. 

[12]   Aginam, Obijiofor.  Supra note 7.

[13]   Infectious diseases largely do not discriminate between persons; however, individual risk factors, including age, general health status, and co-infections, do impact both the likelihood that an individual will acquire a specific disease and the impact of that disease on the individual.  Although the average of persons with SARS was in the range of thirty to forty years of age, young children and olders persons, and persons with other health problems were much more likely to have significantly worse outcomes, including death, brought on by the SARS virus.

[14]   Aginam, Obijiofor.  Supra note 7, at 946.

[15]   Id. 

[16]   Id at 947.

[17]   Id. 

[18]   Id. 

[19]   Id. 

[20]   Id. 

[21]   “Global Drug Use and NIDA.”  NIDA Invest Newsletter.  Edition: Summer/Fall 2002.  National Institute on Drug Abuse. Available at:  Accessed on: January 29, 2003. 

[22]   Id.

[23]   Basic Facts About the United Nations.  Supra note 5, at 165.

[24]   Id at 167.

[25]   Id at 164.

[26]   “AIDS Pandemic: Global Scourge, U.S. Challenge.”  Supra note 10.

[27]   For further information, see generally the Centers for Disease Control and Prevention website at and the World Health Organization website at

[28]   “AIDS Pandemic: Global Scourge, U.S. Challenge.”  Supra note 10.

[29]   Id.

[30]   Schambra, Dr. Philip E.  Supra note 1.

[31]   “About CDC.”  Centers for Disease Control and Prevention.  Available at:  Accessed on: April 10, 2003.

[32]   “Division of Global Migration and Quarantine.”  Centers for Disease Control and Prevention: National Center for Infectious Disease.  Available at:  Accessed on: April 10, 2003.

[33]   Id.

[34]   Exec. Order No. 13,295: Revised List of Quarantinable Communicable Diseases, revoking Exec. Order No. 12,452 of December 22, 1983.

[35]   42 U.S.C. § 264(a).

[36]   42 U.S.C. § 264(b).

[37]   42 U.S.C. § 264(d).

[38]   42 U.S.C. § 265.

[39]   “The SARS Investigation: The Role of CDC’s Division of Global Migration and Quarantine.”  The Centers for Disease Control and Prevention.  March 31, 2003.  Available at:  Accessed on: April 13, 2003. 

[40]   Aginam, Obijiofor.  Supra note 7, at 947.

[41]   Id.

[42]   Id. 

[43]   Id. 

[44]   Id at 948.

[45]   Id at 949. 

[46]   “Declaration on the Trips Agreement and Public Health.”  Adopted November 14, 2001.  Available at:  Accessed on: December 16, 2003.

[47]   “WHO In Partnership: Examples of Work With The Public and Private Sectors to Fight Infectious Diseases.”  Fact Sheet No 235, October 1999.  Available at:  Accessed on: April 10, 2003.

[48]   Id.

[49]   Id.

[50]   Id.

[51]   Edward P. Richards, III and Katharine C. Rathbun, “Public Health Law,” Public Health and Preventive Medicine, 14th Edition, New York: McGraw-Hill, 1998 (1153).

[52]   Id.

[53] “SARS: Timeline of an Outbreak.”  April 15, 2003.  WebMD with AOL Health.  Available at:  Accessed on: April 15, 2003.

[54]   “Update: Severe Acute Respiratory Syndrome – United States, May 14, 2003.”  May 16, 2003 / 52(19):436-438.  Available at:  Accessed on: December 12, 2003.

[55]   “Efficiency of Quarantine During an Epidemic of Severe Acute Respiratory Syndrome – Beijing, China, 2003.”  October 31, 2003 / 52(43); 1037-1040.  Available at  Accessed on: December 12, 2003.

[56]   Id.

[57]   Id.

[58]   Id.

[59]   Id.

[60]   Id.

[61]   Id.

[62]   “Use of Quarantine to Prevent Transmission of Severe Acute Respiratory Syndrome – Taiwan, 2003.”  Available at:  Accessed on: December 12, 2003. 

[63]   Id.  

[64]   Id.

[65]   “Update: Severe Acute Respiratory Syndrome – United States, May 14, 2003.”  Supra note 54.

[66]   Id.

[67]   Id.

[68]   Id.

[69]   Aginam, Obijiofor.  Supra note 7.

[70]   “Global Drug Use and NIDA.”  Supra note 21.

[71]   Schambra, Dr. Philip E.  Supra note 1.

[72]   Sternberg, Steve.  “Better Public Health Training Urged: Preparation for Terror Attacks Needed.”  Gannet News Service or USA Today.  November 5, 2002.  SIRS Database.

[73]   “Update: Outbreak of Severe Acute Respiratory Syndrome – Worldwide, 2003.”  March 28, 2003 / 52(12): 241-248.  Available at:  Accessed on: December 12, 2003.