Bioterrorism: Civil Liberties Under Quarantine
Is the U.S. Legally Prepared for a Smallpox Epidemic?

Listen to Daniel Zwerdling's report on the risks of a disorganized reponse to a potential smallpox outbreak.

Smallpox lesions on a victim in Bangladesh in 1973, one of last outbreaks of the disease in the world. Photo: CDC/James Hicks

Oct. 23, 2001 -- As U.S. officials confront the current anthrax threat, they must also consider how they would contain a terrorist-directed outbreak of highly contagious and fatal diseases such as smallpox or the plague.

Public health officials say the chances of an outbreak might be small, but they warn that a disorganized response could overwhelm law enforcement agencies and threaten civil liberties. On All Things Considered, Daniel Zwerdling reports for NPR and American RadioWorks.

Health specialists are turning to history to try to learn how communities could contain an outbreak of smallpox -- one of the most contagious diseases. Anyone walking within six to nine feet of an infected person is likely to the contract the disease.

Timeline of an Epidemic In February 1972, Yugoslavia is hit with one of the world's last serious smallpox epidemics. Here's how it unfolded: • A Muslim pilgrim carries the deadly virus back from Mecca -- Yugoslavia's first case since 1930. • Falling ill, the pilgrim is rushed to a local hospital where he infects a nurse and eight other patients. • He is transferred to a hospital in Belgrade, where he infects 28 more people, including doctors and nurses. • They infect about 150 others. • In Tito's Yugoslavia, the army is mobilized and martial law declared. • Borders are sealed, unauthorized travel is forbidden. • Hotels and apartment houses are requisitioned and used to quarantine more than 10,000 people. • Within two weeks, two million people are vaccinated; approximately two months after the first case, the epidemic ends. • By 1980, an effort led by the World Health Organization results in the worldwide eradication of smallpox.

Natural occurrence of smallpox was eradicated nearly 25 years ago in a campaign led by the World Health Organization. One of the last major outbreaks hit Yugoslavia in 1972, and experts learned some of the most dramatic lessons about quarantine there.

Smallpox had been absent from Yugoslavia for four decades when a single case emerged in 1972. The virus quickly spread to infect more than 150 people. Yugoslavia’s authoritarian leader, Tito, imposed a sweeping quarantine, walling off the victims from the rest of the population. Those infected were isolated in hospitals, while another 10,000 people who had been in contact with the victims were vaccinated and isolated in hotels. Entire blocks were cordoned off with barbed wire and guarded by police -- essentially creating health prison camps.

America's leaders are in fact considering such drastic steps if an outbreak were to erupt. Just two weeks before Sept. 11, officials at the Centers for Disease Control and Prevention drafted a blueprint for fighting an outbreak: They call it the Bioterrorism Preparedness and Response project. The CDC document specifically warns government leaders that in the event of such an outbreak, they should be prepared to take over private property and impose quarantines.

Researchers warn the United States would face many more hurdles if it tried to impose such restrictions than Communist Yugoslavia did. When smallpox hit Muncie, Ind., in 1893, officials tried to quarantine individual houses. Guards were posted outside the front door of each house to keep the family in and neighbors out. But the townspeople refused to have their freedom restricted, and neighbors simply used the back doors to visit.

Smallpox Fact Sheet Smallpox first appeared in epidemic form at least 3,000 years ago and is estimated to have disfigured hundreds of millions of people since. Caused by the variola virus, the disease is universally feared as the most devastating of all contagions. No proven treatment exists. Most victims survive, but are left with visible scars. Nearly 30 percent of cases are fatal. • Symptoms on average begin appearing 12 days after exposure. • Initial symptoms include high fever, fatigue, headaches and backaches. • Two to three days later, a rash of flat, red lesions appears on the face and arms, spreading to the trunk and legs. • Lesions become pus-filled and begin to crust. Scabs develop and fall off after three to four weeks, leaving pitted scars. • Smallpox is spread person to person by infected saliva droplets. Those infected are most contagious during the first week of illness. • In 1972, routine vaccination ended. By 1980, the WHO declared smallpox eradicated.

As the epidemic spread, officials set aside an entire hospital. Some victims refused to go, using guns to protect themselves, while others had their doors knocked in and were dragged out.

More than 100 years have passed, but law enforcement specialists worry that they would have just as much trouble controlling panicky citizens today. Law enforcement agencies say most police aren't trained to deal with such situations -- treating the sick as prisoners -- and neither are current laws equipped to deal with the 21st century war on germs.

That's one of the touchiest issues: If terrorists did trigger a contagious outbreak, could federal and local officials contain it and also protect civil liberties? Larry Gostin, a lawyer and public health specialist at Georgetown University, says government officials could hurt America by overreacting in a panic. But he says it is possible to maintain tolerance, fairness and due process of the law during an epidemic.

Gostin has drafted a model law that all the states could pass to help them contain an epidemic and protect rights. For instance, if terrorists triggered a smallpox outbreak tomorrow, officials in many states wouldn't have the power to seize private buildings to ease crowding in hospitals. Under Gostin's proposed law, they could seize private property, but they would have to compensate the owners fairly.

Researchers do believe that if the government is really prepared to handle a major outbreak, they might not need such a heavy hand. Health officials say most people could live nearly normal lives during an outbreak if the public was alerted to watch for symptoms and then stay home the instant they saw them -- and if public health officials could keep on top of every potential case. But, say researchers, most government officials have a lot of planning to do before they're ready to handle an epidemic.

In Depth

• Read NPR.org coverage of the anthrax threat.

Other Resources

• Read an assessment of local bioterrorism preparedness efforts, from the National Association of County and City Health Officials.

• Read an article on the legal challenges a large-scale bioterrorism attack would present, from the journal Clinical Infectious Diseases.

• Read a briefing memo for a July 2001 congressional hearing on Dark Winter, an exercise designed to simulate a possible U.S. reaction -- including the use of quarantine -- in the event of a bioterrorism attack.

• Read Smallpox: Clinical and Epidemiologic Features, profile by D.A. Henderson, director of the Johns Hopkins University Center for Civilian Biodefense Studies.

• Visit the Web site for the Johns Hopkins University Center for Civilian Biodefense Studies.

• Read the World Health Organization's statement on the current threat of smallpox as a bioterrorism weapon.


American RadioWorks is the documentary project of NPR News and Minnesota Public Radio. Rebecca Davis produced the story.