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In March, when New York City became the epicenter of the nation’s emerging COVID-19 outbreak, many residents fled.

Some went to Rhode Island, stoking fears that the virus could follow.

So Rhode Island state police and National Guard troops started pulling over drivers with New York license plates to remind them to quarantine for 14 days.

quickly came under fire.

That’s because, according to many legal experts, is unconstitutional.

Rhode Island’s policing blunder is one of numerous shaky starts and stumbles made by government officials struggling to design COVID-19 travel quarantine orders that are science-based, fair and effective.

All told, 18 states and the District of Columbia now require at least some incoming travelers to quarantine for 14 days upon arrival — but experts say many of these policies have glaring design flaws. 

“If a state is going to do any kind of travel ban or quarantine and do it in a way that is effective as opposed to doing it for show — and we’ve had a lot of pandemic performance going on — then it really needs to be based on clear and transparent criteria,” said Wendy Parmet, a public health lawyer in Boston.

“Unfortunately a lot of the measures around the country have not had that kind of clear criteria and they’ve had a lot of changes and exemptions that undermine them.”

But Hawaii, many experts say, is uniquely positioned to pull off an effective quarantine due to its geographic isolation, relatively small population and the fact that most travelers cannot move between the state’s counties without passing through a government-regulated checkpoint at a major airport or harbor.

The Problem With Quarantine Exemptions

In the absence of national quarantine rules, a patchwork of radically different state and regional policies has emerged.

There are but a 14-day quarantine is required for many travelers arriving to Chicago.

All travelers to New Jersey from states with a COVID-19 positivity rate of 10% or higher must quarantine. But this rule doesn’t apply to people spending less than 24 hours in the state.

Residents of New York, New Jersey and Connecticut are exempted from each other’s quarantine rules because people who live in the New York tri-state area commonly live and work in different states.

When a government exempts large populations from a quarantine policy on the basis of their residency, the efficacy of this public health tool deteriorates, Parmet argues.

“The fact that metropolitan areas are integrated across state lines just sort of dooms their quarantines and travel bans to be more performative than real,” she said.

Brian Higgins, an adjunct professor at the John Jay College of Criminal Justice in New York, said exemptions make quarantine orders difficult to enforce.

That’s in part why the former New Jersey police chief favors enforcement through education.

He supports Vermont’s method of relying on voluntary quarantine compliance. Instead of arrests or fines, Vermont police and the reasoning behind them.

“Enforcement is good when someone is just flagrantly breaking quarantine,” Higgins said. “But this is really an opportunity for police-community relations. There are just too many people traveling for anybody to be doing effective enforcement.”

Unlike Most States, Hawaii’s Quarantine Could Work

If any state could implement an effective quarantine policy, many experts say it’s Hawaii.

“Being able to actually screen people and actually control the movement in and out of the state is much easier for a place like Hawaii than it is for a place like California, which borders multiple states and has multiple big airports that are linked to multiple international cities,” said Christopher Kindell, a post-doctoral fellow at the University of Chicago who is writing a book on the history of infectious diseases in the Pacific.

“It’s also easier to track the movement of people and the transmission of infectious diseases within Hawaii because travel between the islands requires a mode of transportation that often is regulated by the state,” he said. 

New Zealand is an example of a government that has managed to . But the country’s success at curbing the coronavirus is only partially owed to its quarantine order, which requires travelers to book a government-monitored quarantine hotel room and isolate there for 14 days upon arrival.

An equally important component is New Zealand’s robust interior testing strategy, which helps officials anticipate an outbreak before it explodes.

But even a well-designed quarantine has the potential to be dangerous, Parmet cautions.

That’s what health officials say happened when the virus penetrated Lanai for the first time in October.

Because there appeared to be little to no risk of contracting the virus in the community, some residents loosened their adherence to social distancing guidelines.

So when the virus eventually found its way in, it ignited a dangerous cluster of more than 100 cases in a matter of days.

“I think that’s actually the same problem that the United States on a whole faced with the travel ban to China,” Parmet said. “It was the illusion that it protected us — and it didn’t. You didn’t notice that a horrific outbreak was forming on the east coast because you weren’t looking for it. And you weren’t looking for it because you had banned travel from China.”

Lessons From Quarantine Island

Experts say its tricky to generate public buy-in for quarantine policies when the consequences of being subject to one can be so severe: lost income, family separation, extreme boredom.

“Every public health official today understands that quarantine and isolation is scary and people don’t like being told that they have to practice those things,” Kindell said. “And they know based on generations of experience that quarantine can go sideways very quickly.”

Hawaii has a colorful history of serving as a disease checkpoint in the Pacific dating to the late 1800s, when quarantine rules and enforcement were far more draconian than they are today, Kindell said.

In 1868, the inaugural trans-Pacific steamship connecting California and Hawaii arrived in Honolulu, introducing a new era of travel along with a new pipeline for contagious disease: There was a reported smallpox case aboard that first steam vessel.

This led to the creation of Quarantine Island, a small manmade isle at the entrance of Honolulu Harbor.

Known today as Sand Island, this quarantine station is where public health officials through the early 1900s sequestered people believed to be infected with a communicable disease.

As a result, people on Oahu during an outbreak would commonly hide themselves from government officials if they were experiencing symptoms of a sickness that was classified as quarantinable.

According to Kindell, infected Hawaii residents were sometimes kept isolated on the island for many months. There are a few cases where patients attempted to swim back to Honolulu and drowned, he said.

“We’ve seen throughout the course of the past 200 years, especially in Hawaii, that it’s been exceptionally difficult to convince and to encourage people to actually isolate and to quarantine when there is a suspicion that they may have a particular disease,” Kindell said.

“Even if public health officials can come up with a good plan,” he said, “it only works if the public is willing to cooperate.”