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The coronavirus Diamond Princess quarantine was doomed. But so are most
quarantines.

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Hot Take


THE CORONAVIRUS DIAMOND PRINCESS QUARANTINE WAS DOOMED. BUT SO ARE MOST
QUARANTINES.

No one would argue that medicine today is the same as medicine in the 14th
century, and very few people are looking for 14th century treatments in the 21st
century.

Passengers stand on the balcony of the quarantined Diamond Princess cruise ship
anchored at a port in Yokohama, near Tokyo, on Feb. 21, 2020.Eugene Hoshiko / AP
Feb. 22, 2020, 10:34 AM CET
By Kelly Hills

On Feb. 1, a man in Hong Kong was diagnosed with COVID-19, the new coronavirus.
A few days earlier, he had disembarked a cruise ship whose name would soon be
known around the world: the Diamond Princess. A mandatory quarantine placed on
the ship by the Japanese Ministry of Health ended on Wednesday, even as dozens
more cases have been diagnosed, bringing the total of sick cruise passengers to
around 450. Clearly, the crisis is not exactly in hand, leaving everyone with
one simple question: Do quarantines like this one even work?

Clearly, the crisis is not exactly in hand, leaving everyone with one simple
question: Do quarantines like this one even work?

This isn’t a new question for America, or even the world, to grapple with. In
2013-16, West Africa experienced the worst outbreak of the ebolavirus disease to
date, and multiple kinds of quarantine were implemented, both within the
affected countries of Sierra Leone, Liberia and Guinea and in other countries.
Within the U.S., a public health nurse, Kaci Hickox, was placed in a tent
connected to a hospital, with a port-a-potty and a telephone, and told to sit
and stay for 21 days, solely based on the fact that she had come back from a
Doctors Without Borders assignment in Sierra Leone. While Hickox didn’t have a
fever on an initial test, after several hours in a warm interrogation room, she
had a flushed face that registered a temperature on a forehead scanner.




Hickox successfully fought her quarantine, arguing — correctly — that the
ebolavirus is not contagious before symptoms, and it would be perfectly safe for
her to remain in her community and self-monitor her symptoms for the known
incubation period while checking in with a public health officer.


STANDOFF CONTINUES AS NURSE KACI HICKOX DEFIES EBOLA QUARANTINE

Oct. 30, 201402:50


The basis of this argument comes from the idea that quarantine is a coercive
measure that infringes upon people’s rights. If you are going to use it, you
better have a really good reason for it. Specifically, you need to show that
it’s a proportional response to the severity of the disease — not just how
contagious it is, but also how harmful it is. You have to show that it’s
necessary, that a community monitoring system like they’re using in the U.K.,
where health care workers advise, monitor and even test possibly sick residents
over the phone, can’t work, and that self-reporting of symptoms also wouldn’t
work. The public has to understand what’s going on, and why, and it should be
clear that quarantine is the option that infringes the least on everyone. And
perhaps most important, it’s got to be effective in stopping the spread of
disease.

Cruise ships, it turns out, are not good places for quarantines — surprising
nearly no one with a public health background. Cruise ships are a confined
space, and we know from past outbreaks that viruses really like to run rampant
in confined spaces. This is most classically seen on cruise ships with
norovirus, but there have also been outbreaks of measles, E.coli, influenza, and
chickenpox; a U.S. submarine, another confined space, recently had an outbreak
of mumps. There’s a reason, after all, why some public health specialists refer
to cruise ships as floating petri dishes.


RELATED

Opinion


OPINIONCRUISE SHIPS ARE DANGEROUS AND DISEASE-PRONE — HOW ARE THEY STILL A
THING?

But it also turns out that cruise ships aren’t a good place for quarantine
because quarantine itself is a problematic concept, rooted in an ancient
understanding of how disease spreads. The name itself comes from 14th-century
Venice, where political and public health policy required ships from possibly
plague-ridden countries to remain isolated for 40 days, giving any incubating
diseases a chance to run their course. The number 40 itself was selected partly
for its religious connections, and partly because the dominant medical system of
the day said that disease was spread via miasma, or poisonous vapors, and it
took 40 days to isolate, fumigate, disinfect and purify the “bad air.”



The idea of quarantining cities isn’t new, either — historically called cordon
sanitaires, they used city walls or soldiers to separate the possibly sick from
the well. You could opt to close the gates and keep out stick people … or keep
them in. Or more precisely, keep their foul air contained. The most famous of
these was most likely the 18th-century Austro-Hungarian Pestkordon, which
stretched nearly 1,200 miles in an effort to stop plague from repeatedly
invading Europe. Of course, like most of these efforts, the actual disease it
was preventing had circulated out of the population nearly 15 years before the
wall was complete.



More recently, during the 2003 SARS-CoV-1 epidemic, Hong Kong enacted quarantine
protocols first designed to handle plague in the 1890s. In one well-known
incident, when police officers arrived at an apartment complex to order everyone
inside to remain quarantined for 10 days, they found nearly half of the 264
apartments empty: People had read the news, heard what was coming and left
rather than be contained. It is estimated that in Toronto, which also
experienced a large quarantine in an effort to stop SARS, 43 percent of people
violated the quarantine.

In the Ebola outbreak in 2014, Doctors Without Borders said it was their
experience in Liberia and Sierra Leone "that lockdowns and quarantines do not
help control Ebola, as they end up driving people underground and jeopardizing
the trust between people and health providers.”

In the process, quarantines can cost governments huge sums and possibly help the
spread of disease by pushing panicking citizens out of their daily routine,
homes or even cities.

So while history tells us quarantines have been around for over 600 years,
history also tells us they’ve never been particularly effective, either because
of an incorrect theory of how disease works, an incorrect understanding of human
behavior, or because every way station and city seemed to have its own rules for
when to quarantine a person or cargo. It’s kind of like we are seeing now with
the Diamond Princess passengers. In the process, quarantines can cost
governments huge sums and possibly help the spread of disease by pushing
panicking citizens out of their daily routine, homes or even cities. Or in the
case of cruise ships, quarantines set up an ideal laboratory to spread disease
between individuals.

None of this is to say that countries have no options in the face of an
outbreak. Authorities can enact basic social distancing measures, like limiting
the ability of large groups to get together, whether it’s for a concert or the
Lunar New Year, or even closing down big office buildings. Other options include
reminding people to engage in cold prevention measures, like washing your hands
frequently (and correctly), avoiding touching your face and eyes, coughing or
sneezing into your elbow, and not shaking hands. Finally, authorities can
encourage people who feel sick to stay home and monitor their symptoms,
contacting a doctor if they have any concerning symptoms.


RELATED

Opinion


OPINIONWE WANT TO HEAR WHAT YOU THINK. PLEASE SUBMIT A LETTER TO THE EDITOR.

No one would argue that medicine today is the same as medicine in the 14th
century, and very few people are looking for 14th century treatments in the 21st
century. We owe it to everyone to treat potentially exposed/ill patients in a
21st century manner, as well. Especially when the data tells us two things:
Quarantine is an out-of-date concept to treat disease, and a cruise ship is the
last place you want to hold an impromptu one.



CORRECTION (Feb. 23, 12:50 p.m. ET): An earlier version of this article
misidentified the cruise ship recently quarantined by the Japanese Ministry of
Health. It is the Diamond Princess, not the Diamond Prince.

Kelly Hills

Kelly Hills is a founding bioethicist of the consulting firm Rogue Bioethics,
where she advises on a broad range of topics, including novel technologies, such
as synthetic biology and genome editing. Her current academic projects involve
international bioethics, biosecurity and infectious diseases research.



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