The severe acute respiratory syndrome (SARS) epidemic has been one of the most dramatic transnational infections of recent times. Images of entire populations of countries carrying on their daily activities with facemasks have perhaps no precedent in the history of man’s struggle against infectious disease, except in science fiction movies. Inevitably, there has been a scientific debate surrounding the exact origin and nature of the virus, which will go on for some time. At present, the epidemic seems to be on the wane.

In their zeal to contain the spread of the disease, many countries adopted strict quarantine policies and put restrictions on travel. Apparently, those who had stricter quarantine policies controlled the epidemic earlier. However, many contentious issues have emerged from such policies.

Unbridled powers of quarantine

A fundamental question which touches the fields of public health policy, medical ethics and human rights is whether the state has a right to forcibly quarantine a suspected patient for the larger common good? Quarantine is an old and established method of controlling infectious disease. The logic that the state’s public health responsibility gives it the right to isolate infected individuals seems to be historically acceptable to society. Even in the setting of SARS, quarantine was accepted as a viable way of controlling the infection. Arguments about infringement of individual liberty were almost non-existent. In fact, medical professionals argued that the loss of liberty was a price worth paying (1). Whether such unbridled powers of ‘quarantine’ could be abused by a state remains an open question.

Even if the rationale behind quarantine is accepted, it is not clear how this can be enforced. Further, the methods of enforcing the quarantine have demonstrated serious violations of individual liberty and ethical principles. The grotesque publicity in the media related to reported SARS patients (some of whom were later tested negative) is one such example. Not only were the names of some patients revealed but their addresses, occupations, family details were made public as well. In the process, we saw a fundamental ethical principle being violated—that of the patient’s right to confidentiality and privacy. Patients have now gone on record to say that since their names were revealed they are being shunned by their neighbours and colleagues. In a particularly extreme example of this phenomenon, members of a housing society in Poona accosted the state’s Director of Health Services demanding that a family reported to be affected by SARS be shifted out of the housing society (2). It is likely that many of these individuals (including those who later tested negative) will continue to face discrimination for some time to come.

Need to respect patients’ rights

Most rational individuals are likely to agree to be quarantined in the interest of their families and fellow citizens. However, there could have been a more humane method of enforcing quarantine while respecting the patient’s dignity, privacy and autonomy. For example, the patient could have been given a choice of institution, or even quarantined at home. The patient’s identity could have been kept confidential, restricted to the treating doctors and hospital staff. Patients and their families could have been counselled, on the basis of available information from other countries, about the infectivity and natural history of the infection, emphasising the fact that a large majority of patients stage an uneventful recovery. Ideally, patients could be counselled even before being tested for the disease. Finally, patients could have been offered decent medical and psychosocial care during the quarantine process.

In the case of SARS in India, however, the exact opposite was done. The authorities’ methods created confusion, used coercion and spread panic. Suspected patients were banished to infectious disease hospitals, like criminals to jail. Most of them were ignorant of their medical problem—some did not even know whether they had tested positive. Some of them heard about their test results from the media! In Kolkata, a patient pleaded with the government to ‘release’ him from a hospital as the hospital staff were discriminating against him in their treatment. In Mumbai, one patient was reported to have ‘escaped’ from an infectious disease hospital after being disgusted with the treatment he was receiving. The Newspaper reported that’action’ was being contemplated against the superintendent for allowing this ‘discharge’ (3). In Nashik, the entire staff of a nursing home was in ‘quarantine’ as news reporters camped outside trying to capture them on camera.

It may be pertinent to note that under normal circumstances the state shows very little interest in its infectious disease institutions. For example, in Mumbai, the municipal corporation-run Kasturba Infectious Disease Hospital has been a victim of neglect for many years. It is ironical that the same system, which completely ignores the health needs of the common man, was remarkably energetic and efficient when dealing with SARS, as it literally hounded every case with even the slightest suspicion of infection.

Responses of doctors, civil liberties groups and media

While the SARS drama was being played out under the glare of the media. The medical profession responded in a predictable fashion. Those in public hospitals fell in line with the state’s methods. The private sector put its hands up and shifted patients to ‘infectious disease’ hospitals. Medical professionals demanded ‘adequate protection’ before treating people suspected to have SARS. Medical associations remained silent both on the scientific and ethical issues. Even civil liberty and human rights groups ignored these events and the issues they raised. The role of the media, which gave excessive and premature coverage to all reports of anything even slightly resembling SARS, and which threw confidentiality to the winds, was dubious to say the least.

As this piece is being written, the SARS story has slowly shifted from the newspapers’ front pages to the inside pages. The paparazzi have had their share of interesting prime time news pictures. For those who were quarantined, the nightmare has probably only begun. For the rest of us, another epidemic has passed.