A Historic Quarantine

China’s attempt to curb a viral outbreak is a radical experiment in authoritarian medicine.

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Editor’s Note: Information about the novel coronavirus is rapidly changing. As a result, some of the information or advice in this article may be out-of-date. You can find The Atlantic’s most current COVID-19 coverage here.

A construction team is racing to build a new, 1,000-bed hospital in the next six days. As a virus spreads through one of the world’s largest cities, no one is allowed to leave. When the count of the dead in Wuhan, China, reached 15 yesterday, government officials declared a quarantine. Trains and public transit came to a halt, and air travel was canceled. Residents were urged to stay at home, and to wear masks if they must go out. The state told people not to spit, and “not to spread alarmist rumors.”

In short order, infections were also confirmed in multiple other parts of China. Travel was also banned in the cities of Huanggang and Ezhou. As of today, the state has essentially quarantined an area estimated to encompass 35 million people—a population greater than the 10 largest U.S. cities combined.

The unprecedented intervention paints an apocalyptic scene. Around the world, stock markets fell. Images of health officials in full-body suits scanning foreheads of passengers on airplanes have drawn everything from dark jokes to earnest concern that this must be the end of the world.

Based on what’s known so far, the virus is dangerous—but not unprecedentedly so. It has been confirmed to spread among people who are in close contact—family and health-care workers—but it does not clearly show sustained transmission among people, like other coronaviruses that can manifest as the common cold. The virus seems to have an especially high mortality rate, though of the 26 people reported dead so far, most have been of advanced age or chronically ill—a similar demographic to the hundreds of thousands of people killed every year by the influenza virus.

Yesterday, the entity best positioned to orchestrate an international response, the World Health Organization, declined to declare the outbreak a public-health emergency of international concern. New coronaviruses have the potential to cause a massive pandemic that kills millions of people. But so far, the most deadly coronaviruses—SARS and MERS—each killed fewer than a thousand. Both were tragic, but could have been exponentially worse.

Part of the fear and panic in the current case seems less due to the virus than to the response. The moderately virulent nature of the pathogen seems at odds with the fact that the largest quarantine in human history is now taking place in an authoritarian state. People inside and outside of China have limited trust in the information they receive, given the country’s long history of propaganda and censorship. Without knowing everything that the state does, international officials have been hesitant to criticize its response. But there is good reason to believe that the quarantine itself will have significant consequences.

Quarantines were common during Europe’s plague-addled Middle Ages, and continued to be the primary means of controlling outbreaks until 1900. Especially after the advent of antibiotics and diagnostic testing, the relative harms began to outweigh the benefits. International agreements were put in place to limit the practice as a matter of justice, because of the burden it placed on people and economies, in addition to basic questions of effectiveness. Quarantines may be used in isolated cases, especially before an outbreak is widespread. But in China, given the advanced spread of the outbreak—the new virus was first reported to the World Health Organization just three weeks ago and has since been found in Japan, South Korea, the United States, Thailand, Singapore, and Vietnam—some experts believe any window for effective containment has passed.

China has a political stake in the appearance of an authoritative response. The regime was chastised for a slow response and concealing information in 2003, during the SARS coronavirus outbreak. This time, China’s action seems to be veering in the opposite direction. As the analyst Bill Bishop put it, “They will stop at nothing to try to control and then eradicate it.” Yesterday, the director-general of the WHO, Tedros Adhanom Ghebreyesus, praised China’s “cooperation and transparency” in dealing with the outbreak.

But China’s past handling has many global-health advocates skeptical, and reports from inside the country vary as to the levels of preparedness and panic. Shortly after the quarantine was announced, The Washington Post reported increases in the cost of food in Wuhan. Some citizens have reported empty grocery shelves. Bishop describes a crisis of faith in the information people are getting; they’re unsure whether they can trust assessments of danger, and fear it could be much worse. Social-media posts describe people being unable to get access to medical facilities for viral testing. Other posts on social media about the scope of the outbreak have inexplicably disappeared, prompting accusations of censorship and further uncertainty.

The basic argument for quarantining is that in emergency scenarios, individual rights must be sacrificed for the collective interest. In the U.S., the constitutional basis for quarantining is somewhere between tenuous and nonexistent, depending on which legal expert you ask. A massive imposition like China’s would be unconstitutional, according to James Hodge, a health-law professor at Arizona State, who noted the likelihood of human-rights violation in such a scenario. Another skeptic, the Georgetown University legal scholar Alexandra Phelan, likened China’s response to a “sledgehammer.”

In theory, a sledgehammer sounds good and decisive. But responding to an emerging epidemic requires precision closer to brain surgery. Shutting everything down may help contain the virus—but also may help spread it by keeping people concentrated in crowded cities. This can create other health issues related to scarcity of resources and intensify panic. Quarantines can actually prevent treatment and detection if they are seen as punishments for reporting symptoms. If people do not trust that doctors and health officials have their best interest at heart—or if people believe them to be acting on a political imperative from above—they are much more likely to play down or ride out symptoms. If this happens, it takes longer for everyone to have a sense of the scale and scope of the outbreak, and to understand how it spreads.

This effect is especially possible in authoritarian states, but crises invite unusual exercises of state power anywhere. The Centers for Disease Control and Prevention quietly expanded its authority to detain people without due process in 2018, despite the concerns of some legal and human-rights advocates. In 2014, before he was president, Donald Trump called for extreme isolationism during the Ebola outbreak, including shutting down all flights between affected countries. The Obama administration, meanwhile, monitored some 10,000 Americans for 21 days and caught zero cases of Ebola. A health-care worker who had been in Liberia was kept in quarantine in Connecticut despite testing negative, sparking a lawsuit from Yale’s Global Health Justice Partnership and the American Civil Liberties Union, which argued that Ebola quarantines violated individual rights and undermined efforts in West Africa.

Whether or not the new virus in China spreads globally to a significant degree, it will raise serious questions about global preparedness for pandemics, and what constitutes a strong response. Last year, the Johns Hopkins Center for Health Security modeled what might happen if a coronavirus outbreak reached the U.S., and found it could kill 65 million people. Among the lessons of the model was that no country can be prepared on its own. A coordinated global response is key to understanding such an outbreak—how it spreads, how to detect and treat the disease, and how to prevent further spread. There are early signs that this is happening. Scientists have praised Chinese colleagues for rapidly sharing the genome of the virus with the rest of the world. This week, scientists at the National Institutes of Health reported that they are already working on a vaccine prototype, which could be available within three months. Scientists at Johns Hopkins have started a crowdsourced site for genomic information and a map of cases.

This is all contingent on people being transparent and honest, and having reason to believe what they hear. People who trust the information they’re getting are more likely to actually take the actions needed—and to believe that things like staying at home during an outbreak are both safe and necessary. Any state that sows distrust in science and journalism, and lacks a solid foundation of trustworthiness, places itself and the world at risk.