Mandatory Ebola quarantines may seem harmless. What's the problem, after all, with telling doctors to stay home for 21 days, maybe catch up on Netflix (at home, in a hospital bed, wherever) and prevent any risk of a vicious disease spreading?
It seems like a logical response to a deadly disease; a recent Politico poll found 80 percent of Americans support Ebola quarantines. But public health experts are lockstep against mandatory quarantines like the ones New York and New Jersey have embraced, which require returning health workers to spend three weeks at home or in a hospital.
The Infectious Diseases Society of America says mandatory quarantines carry "unintended negative consequences without significant additional benefits." More evocatively, a New England Journal of Medicine editorial opposing such policies warns that quarantining returning Ebola workers "is like driving a carpet tack with a sledgehammer. It gets the job done but overall is more destructive than beneficial."
Behind these fears is the belief that these quarantines will do nothing stop the spread of Ebola — but that they will become a huge deterrent to workers volunteering in West Africa, and that, in turn, will help the disease spread faster and further.
Quarantines do little to stop the spread of disease
Ebola gives health workers one huge advantage: the disease makes itself known before it becomes contagious. Patients can only spread the disease after they develop Ebola symptoms like fever or diarrhea. Fears that a doctor or health worker will ride the subway before feeling sick and end up infecting everyone are unfounded.
"One of the major things we have going for us is that it requires direct contact to spread and people don't spread Ebola when they're not symptomatic," says Tom Talbot, chief epidemiologist at Vanderbilt University. "
And that gives health workers a better way to treat Ebola than quarantines: active monitoring, where health workers who have worked with Ebola are screened for symptoms twice daily, and brought into isolation and treatment as soon as any risk signs appear.
"If we couldn't monitor their symptoms actively then that would be different," says Dr. Jeff Duchin, chair of the Infectious Diseases Society of America's public health committee. "But we can. We can get them into isolation and treatment at the first sign of symptoms. And so there's no risk to the public."
And it's not as if health workers don't want to cooperate. "Health workers are very eager to get into medical facilities as soon as anything begins going wrong," Duchin continues. "That's their best chance for survival."
This is one big reason that health professionals dislike quarantines: there's a similarly effective, but much gentler, way to monitor Ebola patients. Quarantines sound good on television but they don't offer any particular medical advantage over active monitoring — and active monitoring doesn't destroy people's lives for three weeks after they've done some of the hardest, most traumatizing work on earth.
Quarantines are a punishment for those who have already faced terror
Consider the case of Daniel Bausch, an Emory professor who has run an Ebola ward in Liberia. He describes the pain of this work. "It's very personal," he says. "People I've worked with, a lot of people who are friends and colleagues, have died."
Or look at the case of Kaci Hickox, the Doctors Without Borders nurse detained at Newark Airport. This is what she thought about while she was held, in a tent, even after her Ebola test came back negative:
I recalled my last night at the Ebola management center in Sierra Leone. I was called in at midnight because a 10-year-old girl was having seizures. I coaxed crushed tablets of Tylenol and an anti-seizure medicine into her mouth as her body jolted in the bed.
It was the hardest night of my life. I watched a young girl die in a tent, away from her family.
Imagine coming back from that experience and being told: You cannot see anyone you care about. You cannot go out in public. You will stay alone in a tent, too. You will spend the next three weeks without any human contact whatsoever. You cannot see your spouse, your kids, or your friends. And, by the way, thanks for your service.
"Nurses and doctors everyday risk their lives for patients," says Linda Greene, an infectious disease specialist and board member of the Association for Professionals in Infection Control and Epidemiology, which opposes Ebola quarantines. "Our approach to them, when they return, is punishment. Three weeks is a long time."
Greene says she could see herself supporting a ban if the evidence was different. If we knew that doctors or nurses could easily spread Ebola by going to the grocery store or bowling alley, there might be reason to bar such activities. But that evidence just doesn't exist — and active monitoring is a smarter tool.
"We definitely support the twice-a-day monitoring and temperature taking," Green says. "But the idea of voluntary quarantine is probably overkill. Everything we know about this disease shows it doesn't spread unless someone is symptomatic."
Quarantines will make Ebola worse in West Africa and in America
Quarantines, public health experts warn, will only act as deterrents for doctors and nurses going abroad to fight Ebola. These are health workers who already typically taking leave from their jobs to go abroad and work in West Africa. They are volunteers with Doctors Without Borders, not paid professionals.
Tacking three additional weeks onto that service where they can't go back to their full-time job — possibly without compensation — can be a significant deterrent to those weighing whether a trip to West Africa is feasible.
New Jersey and New York are offering financial compensation to quarantined workers. But think of the doctor in private practice, who knows that the price of going to West Africa is shutting down his or her office for an additional three weeks. That likely means a loss of patients to doctors who aren't going abroad and can see them.
"If you make people lose 21 days of contact, with their family, with their work and with their pay that's a huge barrier and discouragement for people to go abroad in the first place," says Michael Klag, dean of Johns Hopkins University's Bloomberg School of Public Health. Klag wrote a letter to New Jersey Gov. Chris Christie urging him to let a Bloomberg alumni, nurse Kaci Hickox, out of isolation at Newark airport.
Even in America, many of the Ebola response teams are formed through volunteers. "We want health workers in the US to be willing to continue to participate in the care of Ebola patients," says Duchin. "A lot of these Ebola teams are voluntary. If we're going to require inappropriate and excessively severe quarantines for our health-care workers, we're going to deplete the supply available to take care of patients locally as well."
The key to stopping Ebola in America is not quarantines. It is stopping the disease in West Africa — and that requires a lot of trained health workers willing to fight the disease in West Africa. Cases will keep coming into the United States, quarantine or not, if the outbreak continues to ravage Liberia, Sierra Leone, and Guinea. The longer the epidemic rages on, the more people become infected and the more chance the virus finds new hosts to infect and spread further around the world.
The health-care systems in this region desperately needs more health care workers. "We have a woman who is an alum who is Liberian, and is working in Libera now," says Klag. "What she's said is, the problem isn't money. It's that there are no people left who know how to treat this. Unless we get more people, it's going to continue to spread."
Quarantines will do little to stop the spread of disease. But they can do a lot to stop the movement of health care workers — the exact thing that is necessary to control, and beat, the Ebola outbreak.