FAQ: The Argument Against an Ebola Quarantine for Health Care Workers
The Ebola debate literally took off Thursday morning, when nurse Kaci Hickox defied Maine officials and went for a bike ride in her hometown.
Hickox, who recently returned from treating Ebola patients in Sierra Leone with Doctors Without Borders, has tested negative for the disease and insisted that she’s healthy, asymptomatic, and not contagious. But New Jersey Governor Chris Christie ordered Hickox to be kept in mandatory quarantine in a tent outside the University Hospital in Newark last weekend before she was allowed to be transferred to Maine, where she was supposed to stay indoors.
Maine health officials have said they would make “every possible effort to implement an agreed-upon in-home quarantine,” but Hickox agreed only to two days. During an interview Wednesday, Hickox said she would leave home Thursday morning if the state didn't lift its restrictions, and then she did. The next step is unclear; state health officials have said they plan to seek a court order to compel her to stay home.
Many people wonder why Hickox can’t just stay home—Maine’s Republican Governor Paul LePage said Hickox has the town “scared to death.” According to the latest polls, the majority of Americans support quarantining asymptomatic travelers from West Africa. Politicians from Republican Senator Mitch McConnell to Christie and Democratic New York Governor Andrew Cuomo, have said it just makes sense to order a quarantine, and you don’t need to be a doctor to see that.
So why hasn’t the Centers for Disease Control and the Obama administration embraced quarantines? Here are the arguments.
Okay, what is the main argument against a quarantine?
Health experts argue that a quarantine for health-care workers is an overreaction that does more harm than good. Specifically, why would you go fight Ebola at its source if you’ll be trapped at home for three weeks?
That is the position President Obama has taken as well. On Wednesday, during a press conference with several doctors who worked with Ebola patients in West Africa, the president said that “we have to keep in mind that, if we are discouraging our health-care workers who are prepared to make the sacrifices … then we are not doing our job in terms of looking after our own public safety.”
Volunteers have said they wouldn't have been able to go to West Africa if they'd known they'd be quarantined—even after testing negative for the disease. Ryan Boyko, a Yale graduate student being quarantined in Connecticut, spent three weeks in Liberia helping the Ministry of Health develop a contact tracing system. The Wall Street Journal asked him if he would have gone to Liberia if he knew he’d be quarantined, and he said he couldn’t have. “I am supposed to be TA-ing this semester,” Boyko said. “I would have never been able to get permission to spend six weeks away in advance.”
How does the CDC’s call for a voluntary self-isolation differ from a quarantine?
The CDC’s new guidelines are less restrictive than the mandatory quarantine imposed by New York and New Jersey. It calls for people to voluntarily isolate themselves and avoid public transportation. Christie said earlier this week that the federal policy is confusing and sounds “like quarantine to me,” but the key difference is that it doesn’t treat health workers like pariahs.
The CDC is not recommending that the state keep police cars stationed outside their homes, as happened to Hickox in Maine. It also distinguishes between high-risk people–those who were exposed to body fluids from Ebola patients and weren't wearing protective gear–and lower-risk individuals.
The military has a mandatory 21-day quarantine in place.
True, Secretary of Defense Chuck Hagel announced on Wednesday a 21-day isolation period for military personnel coming back from the infected region. But there is a difference between a volunteer who goes to fight Ebola, then tries to return to normal life, and a soldier. As Hagel said, “they are not volunteers.” After all, they are under orders. They’ll also be getting paid.
What about that Nobel Prize winner who said Christie’s quarantine was a good idea?
As Christie was quick to point out, Dr. Bruce Beutler is on his side:
Beutler shared the Nobel Prize for Medicine and Physiology in 2011 for his research on the immune system, so he’s well qualified to talk about the way the body responds to diseases. He told NJ.com that it’s not certain that people who are asymptomatic can’t transmit the disease. Furthermore, he says he doesn’t trust health-care workers to self-monitor.
But wait: This proves that there’s some debate. An editorial in The New England Journal of Medicine by seven doctors argued that “we have very strong reason to believe” that the disease is only transmitted when a person has a very high viral count. From NEJM:
This understanding is based on more than clinical observation: the sensitive blood polymerase-chain-reaction (PCR) test for Ebola is often negative on the day when fever or other symptoms begin and only becomes reliably positive 2 to 3 days after symptom onset. This point is supported by the fact that of the nurses caring for Thomas Eric Duncan, the man who died from Ebola virus disease in Texas in October, only those who cared for him at the end of his life, when the number of virions he was shedding was likely to be very high, became infected. Notably, Duncan's family members who were living in the same household for days as he was at the start of his illness did not become infected.
I’m not convinced.
That’s fair, and there's a valid argument for being cautious. When Amber Vinson—the second Dallas nurse to be infected in the United States—took a round trip flight to Ohio, the CDC contacted everyone on both flights out of an abundance of caution. When it was found that Dr. Craig Spencer—the New York case—went bowling, the bowling alley was cleaned. In both cases the individuals reportedly didn’t have symptoms when they went out in public, and there have been no new cases reported from those incidents.
But the question now is whether it’s better to calm the public by keeping people who test negative for Ebola and aren’t showing symptoms in forced quarantines for three weeks, or to encourage medical workers to go to West Africa to help stop the epidemic.
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