How Ebola quarantines actually work, explained

As Ebola fears wash over America, some state governors are turning to mandatory quarantines: locking up healthy workers returning from West Africa for 21 days, Ebola's incubation period. The policy in New Jersey made national headlines after it resulted in a nurse who had no Ebola symptoms — and had been fighting the disease in West Africa, no less — being isolated in a poorly heated tent with no running shower or toilet.

Public-health experts see the measure as extreme and unnecessary. President Barack Obama rejected the idea of quarantining health workers, saying it would undermine the relief effort in West Africa. But state politicians are running ahead with quarantines anyway. Here are six things you need to know about the Ebola quarantine controversy:

1) First of all: let's define "quarantine"

Quarantines have been used in public health since since at least 1377, when the Mediterranean city of Dubrovnik (then known as Ragusa) isolated ships suspected of carrying the Black Plague for a 40-day period before letting them enter their ports. But they aren't widely enacted anymore because they often group whole categories of people together, without any consideration of individual risk, impeding civil liberties. 

It's important to distinguish between quarantine, and isolation for infection control purposes. They mean different things, but have been used interchangeably in the news lately.

Isolation separates sick people who are contagious from healthy people, to stop them from spreading their disease.

Quarantine is a preventive measure: it separates healthy people who are at risk of developing an infectious disease from others, to wait and see if they become sick — in the hopes of stopping further disease spread.

In the context of Ebola, a quarantine would involve separating a healthy person who had contact with Ebola patients (e.g. health-care workers returning to the US from West Africa) from others for 21 days. Again, this is different from isolating people who have tested positive for Ebola in, say, a special unit at a hospital.

a quarantine separates healthy people who are at risk of developing a disease to wait and see if they get sick
What a quarantine means in actual practice, however, is something very different. Public health is under states' jurisdictions in the US. Right now, we're seeing a patchwork of confusing and contradictory policies emerge that health experts say are more fear- than science-based.

Some states are enacting mandatory quarantines for health workers returning from West Africa, while the Centers for Disease Control and Prevention has released a new policy that asks only those who believe they may have come into direct contact with the bodily fluids of an Ebola patient to voluntarily quarantine themselves. (More on the specific policies below.)

2) Connecticut, New York, New Jersey, Illinois, Minnesota, Georgia, and the Pentagon now have mandatory quarantines — and they are working out the details on the fly

New Jersey Gov. Chris Christie (L) on the campaign trail with Maryland GOP gubernatorial candidate Larry Hogan. (Photo by Chip Somodevilla/Getty Images News)

Six states, and the Pentagon, have announced some version of a mandatory quarantine policy for travelers returning from West Africa. Each is slightly different, but all center around the idea of restricting the movement of people who are perceived to be at risk of developing Ebola.

Early in October, Connecticut's governor announced he would exercise his power to quarantine people returning from West Africa who were deemed a risk to the community. "We have taken this situation very seriously for months," said Governor Dannel Malloy. By the end of the month, there were eight people in quarantine in his state.

The governors of New Jersey and New York announced their quarantine rules on October 24th. Their policy came a day after the news that a New York doctor, Craig Spencer, got Ebola while treating patients in West Africa — and had taken the subway and gone bowling while he was infected with the disease even though he was not contagious. Spencer is now in treatment for Ebola at Bellevue Hospital and is reportedly in serious condition.

Illinois, Minnesota, and Georgia followed, announcing mandatory quarantines for travelers exposed to Ebola in West Africa on October 27th. These states are allowing people to wait out the 21 days in the comfort of their homes — with the exception of Georgia, which will put high-risk potential Ebola returnees in a designated facility.

Governors appear to be working out the details of these policies on the fly. New Jersey was forced to clarify its rule after a Doctors Without Borders nurse Kaci Hickox went public, even hiring legal aid for what she said was a human rights violation. Instead of confining health workers to a hospital isolation unit, as Kickox was, asymptomatic people who've had direct contact with Ebola will be transported by private vehicles to their homes. For a period of 21 days, they will have "at least two unannounced visits by local officials" to check in.

"Family members would be allowed to stay with the person being quarantined. Friends would also be allowed to visit"
During this time, New Jersey promises that — if a person doesn't have their wages covered by their employer — the state will provide financial assistance, including covering their rent/mortgage as well as a standard per diem. New York's Governor Andrew Cuomo also said that, if employers of the quarantined won't pay them, "the government will."

There's less clarity around the rules in Illinois. There, the governor ordered the state department of public health "to require a mandatory 21-day home quarantine for high-risk individuals who have had direct contact with an individual infected with the Ebola virus while in Liberia, Sierra Leone or Guinea." But when pressed to share the details of the policy, the state said it doesn't involve health professionals who "wore appropriate protective clothing" when working with Ebola victims, but only those who've had skin-to-skin contact.


There also appear to be contradictions in how isolating the quarantines will actually be. In most cases, the people under quarantine can entertain visitors. As a New Jersey press release read, "Family members would be allowed to stay with the person being quarantined. Friends would also be allowed to visit with the approval of the local health department."

If you're confused, you're not alonE Meanwhile, Florida, Virginia, Maine, and Maryland are asking travelers from West Africa who may have had exposure to Ebola to agree to a 21-day quarantine, but they aren't mandating it.

Separately, the Pentagon announced on October 27th that army officials who have been working in Liberia will be forced to stop off in a quarantine facility in Italy for 21 days — even if they had no contact whatsoever with Ebola patients.

If you're confused, you're not alone. These policies are short on detail and have no unifying theme, except that state officials seem to be scrambling to avoid public panic. Because of the lack of clarity, it will be interesting to see how they are actually implemented.

3) The feds do not support mandatory quarantines

Since the first quarantine orders came from New York and New Jersey, the White House has been speaking out against the idea, though it can't overrule state policy.

In an attempt to bring some national consistency to the treatment of returnees from West Africa, the CDC announced a new policy on October 27th. This one ramps up the monitoring of people returning from West Africa, but stops short of a mandatory quarantine.

The CDC only recommends people, including health-care workers, who know they had direct contact with symptomatic Ebola patients (i.e. through a needle prick during a health-care procedure) to go into a voluntary self-quarantine, and avoid traveling, using public transit, and public places.

But all other travelers from West Africa, more or less, just need to be monitored each day, without staying in isolation.

These latest guidelines from the CDC go a step further from the active monitoring that they had already asked state and local health officials to do earlier in October.

4) Pretty much every medical and public health body thinks these quarantines will do more harm than good

Dallas nurse and former Ebola patient Nina Pham with Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. (Photo by Alex Wong/Getty Images News)

The public health and medical communities have unanimously stated that forced quarantines will actually do more harm than good.

"The governors' action is like driving a carpet tack with a sledgehammer," the authors of a New England Journal of Medicine editorial concluded. "It gets the job done but overall is more destructive than beneficial."

The main concern is that this policy is not rooted in science,  and it may deter doctors and nurses from going over to help fight the disease in the place that needs them most right now.

Ebola victims are only infectious after they become symptomatic, and health workers who have fallen ill — like the bowling New York doctor — have promptly been quarantined anyway. Active monitoring, where health officials check patients' temperature twice a day, appears to be just as effective and less restrictive of people's movements.

But, again, maybe locking people perceived to be at-risk of Ebola will calm the public and win a few votes, and for the campaigning governors, maybe that's enough. After all, the costs of mandatory quarantines (worsening the fight against Ebola in West Africa if American health workers stop going over there) won't harm their campaigns, even if they may harm global public health.

As Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, put it: "First principle: Protect American people. Second principle: Make your decision based on the science." Mandatory quarantines do neither, according to Fauci and his colleagues.

5) Ebola quarantines are good politics but bad for public health

Mandatory quarantines are more about politics than protecting public health. State governors want to appear in control — or as New York's Cuomo put it "one step ahead" — and they probably assume overreacting to Ebola will be seen more favorably by most voters than underreacting.

As Illinois Governor Pat Quinn said, "This protective measure is too important to be voluntary."

Quinn also echoed New Jersey's Governor Chris Christie — who has been doing the most public grandstanding about his state quarantine, and who also happens to have his sights set on the presidency in 2016. Christie said, "If anything else, the government's job is to protect the safety and health of our citizens."

Quinn, like Cuomo, also happens to be up for state re-election next week.

So these governors are doing a careful calculation, weighing the potential harms of over-reaction to Ebola (enforced quarantines of a few travelers) with being seen to be too lax. They don't want to risk having another Ebola patient bowling and taking subway rides — even though that patient posed no actual risk to public health — at the cost of precious votes.

6) What it feels like to be quarantined

Quarantine truly sounds like a sad, harrowing, and anxiety-inducing experience. The quarantined say they are treated like pariahs, even though they have done nothing wrong, and in some cases have been saving lives in Africa.

Researchers have also found that formerly quarantined people report symptoms of depression and post-traumatic stress disorder.

Kaci Hickox, the nurse who had been caring for Ebola patients with Doctors Without Borders in Sierra Leone, went public about her quarantine in a tent outside of a New Jersey hospital upon her return to the US last week (after a traumatic trip to West Africa).

She was kept there with no shower, no TV, and only a portable toilet — even though she was healthy. In the Dallas Morning News, she wrote about what was going through her mind while being quarantined:

Eight police cars escorted me to the University Hospital in Newark. Sirens blared, lights flashed. Again, I wondered what I had done wrong.

I had spent a month watching children die, alone. I had witnessed human tragedy unfold before my eyes. I had tried to help when much of the world has looked on and done nothing.

At the hospital, I was escorted to a tent that sat outside of the building. The infectious disease and emergency department doctors took my temperature and other vitals and looked puzzled. "Your temperature is 98.6," they said. "You don't have a fever but we were told you had a fever."

After my temperature was recorded as 98.6 on the oral thermometer, the doctor decided to see what the forehead scanner records. It read 101. The doctor felt my neck and looked at the temperature again. "There's no way you have a fever," he said. "Your face is just flushed."

My blood was taken and tested for Ebola. It came back negative.

I sat alone in the isolation tent and thought of many colleagues who will return home to America and face the same ordeal. Will they be made to feel like criminals and prisoners?

The New York Times also had a fantastic report on the quarantine experience of the family of Thomas Duncan, the first-ever Ebola patient diagnosed in America. "They all want to get out," a local pastor, George Mason, told the Times. "They want their liberty and to be able to touch and be human beings. But they fear they're not going to be normal human beings again. When I asked them if they heard about the second nurse [who was diagnosed with Ebola after contact with Duncan], Oliver looked at me and said, ‘Are they going to blame us for that?'"

In the Times report, Dr. Howard Markel, a history of medicine professor at the University of Michigan, summed up the experience very well when he said: "It's terrible. It's isolating. It's scary. You're not connecting with other human beings, and you are fearful of a microbiologic time bomb ticking inside you."

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