In September 2006, John Donohue landed in Cumberland County Jail for refusing to take medication to prevent the spread of his tuberculosis.
Legal and health officials described the 54-year-old transient’s case as the first time in Maine that a person was imprisoned to avoid spreading a potentially fatal disease. With disagreement reaching a fever pitch over how Maine should respond to the arrival of nurse Kaci Hickox, who treated Ebola patients in West Africa but has no symptoms of illness, let’s take a look at these two cases.
While some similarities are obvious — a deadly disease, state intervention — they’re less alike than you might think.
Donahue was diagnosed with a contagious illness and infected others.
He was diagnosed with tuberculosis after an arrest for drinking in public. Doctors found he had a dangerous drug-resistant form of the illness, which developed because Donahue received intermittent treatment that he failed to complete before moving to Maine, according to a 2008 Maine CDC report. He exposed more than 100 people to TB at a shelter and at the county jail during previous incarcerations. Six homeless men ultimately contracted the illness from him, according to the report.
While some fear Hickox could potentially infect others with Ebola, she has no symptoms of illness and preliminary tests came back negative for the virus. Even if she was infected, Ebola is transmissible only when symptoms are present.
TB is much more contagious than Ebola.
Caused by a bacterium rather than a virus, TB can spread through the air from one person to another. Ebola, on the other hand, is not an airborne disease. Contracting Ebola requires direct contact with the bodily fluids someone who is both infected and exhibiting symptoms.
While the horror of the Ebola outbreak in West Africa continues to unfold, about 7,500 people have died from the virus in all of history. TB, on the other hand, kills 200 times that many people every year, amounting to 1.5 million deaths in 2013, according to the World Health Organization.
Both resisted efforts by public health officials.
Donohue was initially sent to Maine Medical Center in Portland for treatment, and after two months was transferred to a Massachusetts facility after he was no longer contagious to complete a six-month treatment regimen. Public health officials worked closely with him to educate him about the disease and ensure he took antibiotics, but Donahue declared he planned to stop treatment after leaving the hospital, according to the 2008 CDC report.
The state got a court order to compel him to complete treatment, but he left the facility after eight days. Donohue said he became lonely and bored and decided to take off, according to news reports at the time.
A warrant for his arrest was issued, and after three days Donahue was apprehended and temporarily housed at the county jail. A district court judge ordered him to complete treatment and he was transferred to secure facility in Boston.
Hickox vocally resisted New Jersey’s mandatory quarantine, penning a column in the Dallas Morning News describing the “frenzy of disorganization” and threatening a lawsuit against the state. (Her lawyer says she’s no longer pursuing the suit now that she’s been released.) She’s now saying she won’t adhere to Maine’s protocols for a 21-day quarantine at her home.
“You know I truly believe that this policy [the quarantine] is not scientifically or constitutionally just,” Hickox told NBC’s Matt Lauer early Wednesday morning via Skype from her Fort Kent home. “I am not going to sit around and be bullied by politicians and forced to stay in my home when I am not a risk to the American public.”
According to Dr. Dora Anne Mills, who formerly headed Maine CDC, health officials would need a court order to impose a mandatory quarantine on Hickox. The state could place her in immediate quarantine if the governor declared a public health emergency, but would have to seek judicial approval within 48 hours.
Hickox has a place to go.
Hickox is now back in Fort Kent, where she lives with her boyfriend.
Because Donahue was homeless and needed to be sent to a locked facility, presented a unique set of problems for health officials. They couldn’t quarantine him at home because he didn’t have one, and likely wouldn’t have remained there if he did. The state had no secure setting except for a psychiatric hospital, jail or prison, but officials who oversaw those facilities wouldn’t take him because of the health threat he posed, according to the Maine CDC report.
Maine has no official state quarantine facility. The state can designate facilities and private homes for the confinement and treatment of infected people who pose a public health threat, other than a jail or correctional facility.
The state’s preparedness plans outline the various options for potential outbreaks. Here are the pros and cons of each, as identified by Maine CDC in the 2008 report:
|Potential Options||Staffers||Security24 x 7||Infection Control(neg pressure)||Availability||Licensing||Cultural Issues||Language Access||Comments|
|County Jails||Medical Staff on site||Yes||Only some facilities||Throughout State||N/A||Likely||Likely||Prohibited by 22 MRSA Section 807 Resistance of jail administrators as would be seen as a conflict of missions|
|Nursing Homes||Medical Staff on site||No||Unlikely||Throughout State||Concerns with restricting patient rights. Current regulations prohibit||Unlikely||Possible||Negatively Impacts other residents who see another resident receiving special attention/privileges|
|State Mental Health Facility||Medical staff on site-familiar with psychological issues of patients||Yes||Unlikely||Throughout state but shortage of beds. Beds are not available on short notice||?||Likely||Likely||Laws governing psychiatric admissions preclude use for other purposes|
|Crisis House||Non-medical staff-unfamiliar with transmission of infectious disease||No||No||Exists within state mental health system||Licensing issues||Possible||Possible||Staffing well accepted by mental health patients|
|RFP Community Agencies||Perhaps||No||No||?||?||Possible||Possible||Could be a creative solution for regional approach|
|Rent RV||Who provides staffing?||Who provides security?||N/APatient could live alone||Rent on a “prn” basis/hospice type approach||N/A||Unlikely||Possible||Would be useful for homeless patients; patients whose family does not want to risk further infection (ie young children in household)“Not in my neighborhood”|
|Vacant State Property||Who would staff?||Who would provide security?||N/A as patient could live alone||Already in existence-Not clear where||N/A||Unlikely||Possible||Where is vacant property? What physical shape are these empty buildings in? Who owns? Who needs to provide consent for use?|
|Own Home||Utilize PHN for DOT||Who would provide security?||N/A as patient lives alone or with already exposed family members||Already in existence hospice type approach||N/A||Likely||Likely||Will not be applicable to homeless; inmates|
|Home quarantine ankle bracelet||Utilize PHN for DOT||Unnecessary||N/A as patient lives alone or lives with already exposed family member||Already in existence; hospice type approach||N/A||Likely||Likely||Not useful for homeless; inmates|
|Hospitals||Medical staff on site||Who provides security?||Yes||Hospital throughout Maine||?||Likely||Likely||Expensive place to provide out patient care plus would still require hiring a 24 hour guard|
|Rural isolated facility/island location||Who would staff?||Security still necessary despite nowhere to escape to! Socially reprehensible||Unnecessary||?||N/A||Unlikely||Unlikely||Creative solution but may not be workable. Civil libertarians would have a field day!|
|Regional Approach, New England||Medical staff on site||Yes||Yes||Limited capacity; and final decision to accept patient rests with admitting State and facility||N/A||Likely||Likely||Current capacity of 12 beds in Boston’s Shattuck Hospital would not be adequate for New England’s needs. Concerns regarding legal liability|
Maine health officials may pursue a court order to compel Hickox to remain in quarantine. Donahue served as a valuable test case to help the state fine tune its public health response.