You can't order quarantines forever, and at some point a state of medical emergency becomes a new reality.
In an article last updated today, The Wall Street Journal reported that New York, New Jersey, and Connecticut have instituted a mandate requiring travelers from states they designate as "experiencing a surge in COVID-19 cases," to observe a 14-day quarantine upon arrival.
This mandate that took effect on midnight Wednesday carries with it varying consequences for non-compliance. In New York, a first-time violation merits a fine of $2,000.00 with subsequent violations earning fines of $5,000. Higher penalties would be enforced if the non-compliance caused harm. In Connecticut, there will be no fine, and in New Jersey, the quarantine would take the form of an "advisory."
There's one overarching problem with these mandated quarantines. They're of questionable constitutional import.
Following our independence from England, our nation stood as an inept giant. Yes, it was young. It was also broke, but perhaps even more importantly a powerless Congress led it. Under the Articles of Confederation, our first system of government, the states created a very loose alliance of sovereigns, so loose in fact that they were able to impose harsh restrictions upon each other. Each state could print its own currency, ignore other states' currencies, and restricted interstate travel and commerce. Protectionist laws casting advantages to those citizens living within each state at the expense of their fellow countrymen loomed large, and there was nothing Congress could do about it. Such divisions could never work, and it is for this very reason that the nation's leaders convened a Constitutional Convention with the aim of preventing the disintegration and fractionalization of the young confederacy. Protections against limitations in travel and interstate commerce were chief amongst the corrective measures implemented in the new Republic's founding document.
Clearly, a state restricting an individual to a certain location for a fortnight simply because he or she is from a targeted state acts in a manner repugnant to interstate commerce and individual travel rights. The Supreme Court was explicit in this regard when it decided Saenz v. Roe, (1999). Here, the Court ruled that there are constitutionally prescribed travel protections including "the right of a citizen of one State to enter and to leave another State, the right to be treated as a welcome visitor rather than an unfriendly alien when temporarily present in the second state, and for those travelers who elect to become permanent residents, the right to be treated like other citizens of that State." Interstate quarantines violate all three.
It is true that the governments may claim certain latitudes during times of crisis. For example, Congress is given the authority to suspend the privilege of Habeas corpus, "when in Cases of Rebellion or Invasion the public Safety may require." And the states are afforded certain liberties if "actually invaded, or in such imminent Danger as will not admit of delay." But these contentions do not apply to a pandemic.
President Trump declared a health emergency regarding SARS-CoV-2 on March 11, over 90 days ago. Since that time, we have been able to establish that there is no imminent exhaustion of our medical supplies. Despite "surges" in certain states, the nation's daily new-case rate has flattened. As of this writing, the nation's daily death rate has not been this low since March 30. In New York, arguably the state guilty of the nation's worse COVID-19 mismanagement, there were a mere 742 new cases on June 23, the lowest since March 17, and the daily death rates rival those of March 22.
In the meantime, in Florida, one of those states experiencing a surge, the number of new cases for June 24 was 5,511, but the number of deaths was 45. And to add to the inconsistency in the data, New York carries a 1,611 death per million rate compared to Florida's 153, and an active case per million rate of 294,660 compared to Florida's 84,570.
Adding to the absurdity, Florida presently has a quarantine in place for visitors from New York rivaling the quarantine New York implemented against Floridians on Wednesday, begging the questionjust who needs to be protected from whom?
As I explain in my book, Coronalessons, obtrusive interventions such as quarantines, shutdowns, and border closures only work to keep the virus out of a country. But in America, the virus is already here. In Coronalessons, I also observe the Constitution, miraculous as it may be, is a very fragile document, easily ripped and irreparably destroyed. The right to freely move from one state to another and engage in interstate commerce is one of the hallmarks of our Constitution. Although it may be appropriate to briefly restrict our interstate travel in the name of safety morale, health, or welfare, prolonging these restrictions, as we are presently doing, threatens to hurt us much more than it will aid us.
The only real interventions we can take until the development of a vaccine or definitive treatment is for the elderly and the infirmed to observe social distancing measures, for all of us to engage in frequent handwashing, surface sanitation, and mask use when in public places. More aggressive interventions are mere opportunities for governments and people in authority to extend their ambits of power. It is time for us to end these random and capricious interstate quarantines.
Dr. Julio Gonzalez is an orthopaedic surgeon and lawyer living in Venice, Florida. He is the author of The Federalist Pages, The Case for Free Market Healthcare, and Coronalessons.He served in the Florida House of Representatives. He can be reached through www.thefederalistpages.com to arrange a lecture or book signing.
A controversy has arisen regarding the utility of using chloroquine or hydroxychloroquine with azithromycin in the prevention and treatment of COVID-19. On the one hand, there are the purists who maintain that these medications ought not be employed until the proof of their benefits has been established. On the other, some advocate for the aggressive and immediate deployment of these medications. With these two very valid competing arguments proffered by sophisticated scientists and healthcare providers, the question for the rest of us mere mortals is what should we do?
The first step in addressing this question is to evaluate the state of the literature on the topic. An early indication that hydroxychloroquine or chloroquine in combination with azithromycin could be helpful in the treatment of COVID-19 infection comes from a randomly controlled study from France involving 40 patients with early infection. All patients in the experimental group improved and did better than those in the placebo group, except for one who was 86 years old and received the medicines in an "advanced form" of the disease.[i] But the study suffered from its small size and lack of a peer review process.
Other studies seemed to support the French conclusion. In the laboratory, evidence demonstrates that chloroquine helps defeat the virus by increasing a cell's internal pH and interfering with the penetration of the virus into the cell.[ii] Another study, this time out of China, showed the effectiveness of chloroquine and another medication, remdesevir, against the SARS-CoV-2 virus (the COVID-19 virus) in Vero E6 cells taken from African green monkeys.[iii] Yet another preliminary study out of Wuhan showed that the time to clinical recovery, body temperature recovery time, and cough remission time were shorter in patients treated with hyrdroxychloroquine than in untreated controls.[iv]
There's also experiential evidence suggesting that people who take chloroquine or hydroxychloroquine in low doses may be prevented from even developing the disease. Additionally, informally reported observations find that patients who regularly take these medications for other conditions such as lupus are generally not contracting COVID-19.
But conflicting scientific information has also emerged. One study suggests no benefit to the administration of hydroxychloroquine and azithromycin in patients with severe infection.[v] The severe nature of the infections in these patients is notable, as it appears that the damage to the body goes beyond what an antimalarial can improve.
In light of all this emerging information regarding the potential benefits of administering the drugs it is tempting to conclude that we should treat all COVID-19 patients with these medications. But what about the potential harm? Here, there is extensive evidence of the safety of taking chloroquine and hydroxychloroquine. Yes, either medication can cause retinopathy and changes in heart electrophysiology, but these effects are exceedingly rare and take place in patients who consume the medication at higher doses and for much more protracted periods of time. In reality, the use of hydroxychloroquine or chloroquine in the recommended doses and projected administration times for COVID-19 is very safe.
So should we be taking chloroquine or hydroxychloroquine? Well, the answer actually comes in three packets.
First, with the data available, those patients in respiratory failure ought definitely be treated with a regimen of chloroquine or hydroxychloroquine and azithromcin. They should also be placed on remdesevir. These patients, of course, are generally being treated in the intensive care unit setting, and the optimal management controversy does not apply to the general public.
For those patients who are not in respiratory failure, but are nevertheless infected with COVID-19 the more proper approach is one of drug administration. Although treatment should be undertaken under physician supervision, there is little question that the balance between risk and benefit strongly lands in favor of benefit, especially when one considers the potential imminence of patient demise.
Finally, there is the question of preventive treatment or prophylaxis. Here again, there is a strong suggestion of benefit and a very remote risk of harm particularly when one considers the exceedingly low doses required for prevention. The conflict here lies in supply. Do we have enough chloroquine and hydroxychloroquine to meet the demands from such a broad swath of the population? Ideally, it would be preferable that everyone takes one of these medications, but in light of supply limitations, at the very least, those coming into frequent contact with COVID-19 patients and elderly persons should be on a prophylactic dose.
What about those on chronic regimens of these medications? Should they be kept from accessing chloroquine or hydroxychloroquine as many in the media claim is taking place? They shouldn't. But even in light of temporary shortages the prophylactic use of these medications should still be considered. Let's face it. We are looking at a massive pandemic that is devastating the national economy and able to take some victims with great haste. A short-term interruption of treatment on chronic patients is generally not going to result in their rapid demise, but the contraction of COVID-19 may. Here, urgency considerations definitely fall on the side of the COVID-19 patient and its prevention.
In the end, these are prescription medications so the decisions for administration or not lie with the physician. Ultimately, each physician is going to have to make up his or her mind. However, although there is still some room for debate, the answer presently is falling on the side of administering rather than withholding these potentially life-saving medicines.
Dr. Julio Gonzalez is an orthopaedic surgeon and lawyer living in Venice, Florida. He is the author of The Federalist Pages andThe Case for Free Market Healthcare. He can be reached through http://www.thefederalistpages.com/contact.htmlor at firstname.lastname@example.org.
1. Philippe Gautret, Jean-Christopher Lagier, ""Clinical and Microbiological Effect of a Combination of Hydroxychloroquine and Azithromycin in 80 COVID-19 Patieints with at Least a Six-Day Follow-Up: An Observational Study," MediterranéeInfection (blog) accessed Apr. 5, 2020, https://www.mediterranee-infection.com/wp-content/uploads/2020/03/COVID-IHU-2-1.pdf.
2. Manli Wang, Ruiyan Cao, et al., "Remdesivir and Chloroquine Effectively Inhibit the Recently Emerged Novel Coronavirus (2019-nCoV) in Vitro," Cell Research, Nature (blog), vol. 30 269-271 (2020) elct published Feb. 4, 2020, accessed Apr. 4, 2020, https://www.nature.com/articles/s41422-020-0282-0#citeas.
3. Manli Wang, Ruiyan Cao, et al., "Remdesivir and Chloroquine Effectively Inhibit the Recently Emerged Novel Coronavirus (2019-nCoV) in Vitro," Cell Research, Nature (blog), vol. 30 269-271 (2020) elct published Feb. 4, 2020, accessed Apr. 4, 2020, https://www.nature.com/articles/s41422-020-0282-0#citeas.
4. Zhaowenu Chen, Jija Hu, et al., "Efficacy of Hydroxychloroquine in Patients with COVID-19: Results of a Randomized Clinical Trail," MedRxiv (blog), Mar 22, 2020, accessed Apr. 4, 2020, https://www.medrxiv.org/content/10.1101/2020.03.22.20040758v2.
5. Jean Michel Molina, Constance Delaugerre, et al., "No Evidence of Rapid Antiviral Clearance or Clinical Benefit with the Combination of Hydroxychloroqinie and Azithromycin in Patieints with Severe COVID-19 Infection," Médecine et Maladies Infectieuses(blog), Mar. 30, 2020, accessed Apr. 5, 2020, https://www.sciencedirect.com/science/article/pii/S0399077X20300858?via%3Dihub.