The operational as well as theoretical concept of the “cordon sanitaire” – a French phrase literally translated as “quarantine line” – is one of containment. Originally, cordon sanitaire referred to the segregation of persons suffering from communicable and untreatable diseases from their healthy fellow citizens through use of a physical demarcation of some type – a wall or fence, for example. A “sanitarium” was and is the common manifestation of this concept, and refers to a facility in which diseased persons suffering from tuberculosis, leprosy, syphilis, polio, smallpox, and even mental disorders are separated from the population at large and required to live in separate, often fenced-off, buildings where they would stay until recovering from their diseases, or eventually die.
As a potential countermeasure to a pandemic avian flu, the idea of establishing local cordon-sanitaire facilities has resurfaced in some communities in the form of proposals to designate certain hospitals as “flu only” facilities. In effect, this countermeasure would create flu sanitariums within the U.S. healthcare system. However, although the intention is laudable, there would be significant difficulties in attempting to implement the cordon-sanitaire concept in most of the nation’s communities. Chief among those difficulties would be challenges of authority, of economics, and of scale, as well as various difficulties and challenges related to influenza biology itself.
The “emergency support function” annexes to the national response framework designate various support functions and legal authorities to manage and administer federal, state, and local healthcare assets to solve common problems in the emergency-response field. Emergency Support Function #8 (ESF #8), for example, specifically designates the U.S. Department of Health and Human Services (HHS) to serve as the official “Public Health and Medical Services” authority – and authorizes HHS to receive support from other federal agencies.
Fifty States and a Multitude of Complexities
However, although the ESF annexes might serve as effective administrative strategies, a closer review of the annexes shows that there is no direct authority granted by any of them for the establishment of a cordon sanitaire. In fact, ESF #8 specifically focuses only on the coordination of efforts required between and among public-health authorities, medical subject-matter experts, and local authorities.
The authority postulated in this important federal document extends to the Department of Defense, the Veterans Administration, and other federal agencies – led by HHS, though. But ESF #8 does not allow the federal government to dictate to state health departments what they should or should not do.
It should be emphasized here that state health departments already possess the legal authority to impose a cordon sanitaire on their own. But that authority exists in 50 different versions and must be carried out by 50 different groups of personnel possessing a broad spectrum of different capabilities. Further complicating this key structural difference is the overlay, in most if not all states, of the numerous county and municipal health departments that also have been granted varying degrees of authority to impose a cordon sanitaire.
This diffusion of authority, of course, would be, and is, an obvious and major concern to decision makers at all levels of government. But an even more significant point of concern, probably, is that an estimated 90 percent or more of the nation’s hospitals, doctors’ offices, medical centers, and other healthcare facilities are owned and operated as private businesses. Their owners – private citizens who deliver most of the nation’s medical care – may or may not choose to comply with orders issued by state and federal authorities. Here it should be emphasized that failure to comply with a public health order is a civil offense in most states – but not a criminal offense. The simple fact is that federal or state authority extends to the employees of federal and state health care agencies, but not necessarily to the vast majority of physicians and other private-sector healthcare professionals living and working throughout the United States.
Flying Blind in Flu Biology
One of the keys to the success of a well managed cordon-sanitaire campaign is to determine which citizens have or do not have a particular disease. Unlike smallpox, to cite the most notorious example, a fundamental challenge related to flu biology is that communicability – i.e., the ability to infect another person – almost always starts before the flu patient is aware that he or she is ill. Moreover, some individuals will continue to be infectious even after they recover from the flu.
Another relevant concern is that a pandemic flu travels within a population much more rapidly than tuberculosis, syphilis, leprosy, polio, or numerous other diseases. In addition, because healthcare personnel usually are exposed first, and most often, to those within the general population who are seriously ill, the likelihood is that the influenza will already be well underway within the healthcare-provider population before it is recognized in the general population. Designating a “safe” or flu-free hospital is therefore likely to be a failed strategy from the start if a strong avian-flu surveillance program focused on medical personnel has not been instituted before avian flu is evident in the population of a community at large. There is no such program now in existence in U.S. private-sector medical facilities.
Avian flu is detected by a rather complicated set of analyses, carried out in reference laboratories. But most flu tests are valid only for testing for the common form of the flu – called “Group A.” Moreover, a positive test does not differentiate avian flu from the common flu but only determines that the person tested has “the flu” (of some type). Theoretically, such a determination may be of some administrative use, but no individual who tests positive should have contact with patients and/or work in a flu-only facility. This common-sense requirement represents a two-edged sword for decision makers, because it not only subtracts a number of healthcare personnel from healthcare facilities that have not been designated as flu-only, but also forces those who test positive to be grouped among those who have been exposed to avian flu – whether they actually are suffering from avian flu or not.
Beyond the Boundaries of Common Sense
Another complication to consider: There is no guiding protocol either for trading personnel between competing medical facilities or for compelling private citizens to work in avian-flu facilities against their will. Further exacerbating the situation is the fact that most U.S. hospitals are complex organizations staffed by a relatively large number of personnel –any of whom may violate the boundaries established by a cordon sanitaire if he or she is suffering from an asymptomatic flu infection and works in an area of the facility (the cafeteria, for example) where he or she would be in contact with other personnel.
The designation of a hospital as flu-only would be nothing short of financial suicide for the institution. From a strictly financial viewpoint, most U.S. medical facilities are high-overhead/low-margin businesses. This means that high payroll, equipment, and supply costs are incurred just to open the facility – and to keep it operational thereafter. Largely because of these high overhead costs, almost all U.S. private-sector medical facilities require a 95-97 percent occupancy rate just to remain solvent. In the beginning of a flu outbreak, though, a pre-designated “flu” hospital would be empty or close to it, costing that facility a rather large sum of money. Because the personnel who work at a facility so designated would be at increased risk of contracting the disease themselves, additional precautions must be taken to ensure their safety. These precautions include the use of infectious control supplies, surveillance testing, and medical prophylaxis – all of which involve high additional costs.
Procedures such as bypass surgery, hip replacements, and other elective surgeries generally earn money for most U.S. medical institutions. Medical illnesses such as influenza, however, usually are not money makers for the institution. Leaving aside such questions as the denial of care by insurance companies – which frequently require that their subscribers receive care in their own “network” hospitals – the designation of a medical facility as flu-only means that that facility will be damaged financially at the very time that it needs additional financial support. Here it is relevant to point out that ESF #8 does not designate any authority to compensate for these costs.
Another point to consider: The public perception that a particular healthcare facility has been designated as a “flu” hospital can have lasting effects. Many potential patients may want to avoid treatment of any type, for any medical condition, in that medical facility for a long time to come due to fear of disease – or because the facility may have lost some key personnel to the flu. In short, one of the first and most important casualties in an avian-flu outbreak probably would be any medical facility designated as flu-only.
All healthcare facilities within almost any U.S. community will generally be operating at or near capacity during normal working days. The addition of a significant number of flu patients would create an overload in any case that will be made even worse by designating a hospital as flu-only, because other facilities in the same community must provide care for which there is no additional space or personnel. In addition, the designated flu-only hospital also has a finite capacity and a limited number of personnel. However, most predictions of a potential avian-flu pandemic indicate that even the designation of 25 percent of the medical facilities within a particular community would fall short of the number that would be needed to cope with a major outbreak of the avian flu.
To summarize: The combined problems of unclear authority, flu biology, financial constraints, and the expected scale of pandemic operations create challenges that would be difficult at best to surmount in sudden times of crisis. There also is a significant risk of the public perceiving bias, based upon racial or socio-economic factors, on the designation of specific hospitals as flu-only facilities. For all of these reasons, it is probably a better strategy for all facilities within the same community to develop at least some capability for sustained flu operations, rather than imposing a potentially unwelcome cordon sanitaire on a population unfamiliar with the concept and its short- as well as long-term political, economic, and medical implications.
Dr. Allswede is the Director of the Strategic Medical Intelligence Project on forensic epidemiology. He is the creator of the RaPiD-T Program and of the Pittsburgh Matrix Program for hospital training and preparedness. He has served on a number of expert national and international groups on preparedness.