The standard prescription from the Centers for Disease Control and Prevention for the mildly ill to self-isolate at home is something doctors and nurses in coronavirus hot spots repeat hundreds of times each day. But there’s a devastating cost to the public policy decision: multiple families with multiple deaths.
An 86-year-old matriarch and her three adult sons in New Orleans.
High school sweethearts married for 57 years in Grove City, Ohio, and their son, who had visited recently.
Sisters in Chicago. A mother and daughter in Baltimore.
All dead within days of each other because of the coronavirus.
Amid the family tragedies come increasing calls for U.S. officials to isolate the mildly ill and infectious away from their homes — in convention centers, school gyms, anywhere else.
It’s not just a public health issue but an economic one.
Focusing restrictions more narrowly on the infected and their contacts, so that others can be freed from lockdown, has become a vital pillar of proposals to reopen the country.
The issue is especially critical in light of research that suggests genetics may partly explain the wide disparity in how people react to covid-19, with some shrugging off the virus without even knowing they are infected and others facing death.
On March 30, the World Health Organization’s Michael Ryan warned of a new stage of transmission in countries that instituted lockdowns and social distancing, but left many of the contagious at home.
“In a sense,” Ryan said, “transmission has been taken off the streets and pushed back into family units.”
China’s success with isolating family members separately has been held up as a model for breaking transmission chains. But images of Chinese officials forcibly taking people from their homes drew visceral reactions from many.
“We couldn’t under any circumstance do what China did,” said Thomas J. Bollyky, a senior fellow at the Council on Foreign Relations and director of its Global Health Program. “Large-scale, non-voluntary quarantines would be challenging from a legal point of view.”
Yale University’s Gregg Gonsalves, an epidemiologist, tweeted Wednesday that family separation “is a cruel overreaction and a violation of human rights.”
But other experts, such as Carl Minzner, a professor of law at Fordham University, believe isolation and quarantine can be done voluntarily, in a way that respects civil liberties. Minzner is especially worried about poor people living in dense housing, who, according to early reports, make up a disproportionate number of the infected.
“Many people,” he said, “are terrified about infecting their family members and want to self-isolate but have nowhere to go.”
Several U.S. communities recently began experimenting with isolation centers.
On April 1, Hillsborough County in Florida set up two motels for those who have suspected or confirmed infections and are concerned about exposing vulnerable family members. Wisconsin and North Carolina have done the same in their largest cities. Other jurisdictions have set up “safe” housing for first responders such as doctors and police.
Different countries, different experiences
South Korea, Singapore and Taiwan, which have been relatively successful at controlling the spread of the virus, isolated the mildly ill, while Italy and Spain, where infection rates skyrocketed, did not. Public health experts have said a steady stream of household infections may be to blame for that spike in numbers.
China’s experience may be the most instructive. The country initially ordered people to stay at home. But as infections mounted, it turned to isolation, separating those with covid-19 from non-infected people, and quarantine, separating those who had come in contact with an infected person to see if they also would become sick.
When China shut down Wuhan on Jan. 23, the scope of the lockdown was unprecedented in modern times. Flights and trains were stopped. Public transportation was suspended. All of a sudden, millions were told to stay at home.
Through late January and early February, the city’s hospitals were overrun. With intensive care units packed, people with mild illness were advised to stay home. The problem, of course, was that sick people spread the virus through households.
Some tried to keep family members with symptoms in a separate room. But the virus spread through the city’s apartment blocks. In some case, whole families got sick.
In early February, China adopted a new tactic: mass quarantine and isolation. In Wuhan, more than a dozen makeshift hospitals and quarantine centers were opened.
On a visit to Wuhan, Vice Premier Sun Chunlan ordered medical workers to scour homes for confirmed cases, suspected cases, people with close contact with confirmed cases, and people with fevers.
People who did not cooperate would be compelled into quarantine. The vice premier warned of “wartime conditions,” saying “deserters” would be “nailed to a pillar of historical shame.”
In some cases, healthy people were mistakenly sent to live in close quarters with the sick, fueling the spread of disease. In some facilities, patients languished without adequate care. Social media posts showed people being dragged away against their will to quarantine or isolation.
The opposite approach is also terrifying. Italy’s lack of isolation centers, along with multigenerational households, has been cited as a reason for its high infection and death rates.
Zeke Emanuel, a medical ethicist who was an adviser in the Obama administration; Scott Gottlieb, a physician who was President Trump’s first Food and Drug Administration commissioner; and others who have released detailed plans for how to safely end the crisis have argued that there is a middle ground.
They point to the threat of large fines and appeals to people’s sense of moral obligation to their families and communities as effective strategies used in other parts of the world to get those suspected or confirmed to be infected to leave their homes.
Harvey Fineberg, a former president of the National Academy of Medicine who now heads the Gordon and Betty Moore Foundation, has proposed that the United States consider what he calls a “smart quarantine.”
Anyone who shows symptoms would be separated in a temporary shelter until test results return. If they test negative, they would remain in quarantine and be retested at 14 days. If that second test is negative, they could return home. If they test positive, they would go into a different type of facility for care.
To be effective, he argues, the proposal must be part of a broader strategy: testing, isolating confirmed or presumptive cases, and contact tracing. Isolating the infected wouldn’t be possible in all cases. After all, scientists believe some people are asymptomatic. But it would slow down the rate of infection.
“We have seen from elsewhere, those who are most at risk are the family members of those who have been exposed,” he said.
He said many people would welcome the opportunity to shelter somewhere outside their home, provided there was adequate care.
“I think that a lot of people, when they really saw it as a way to provide maximum protection to their own family, would welcome this,” he said.
One of the nation’s first voluntary quarantine and isolation facilities opened in early April in Florida’s Hillsborough County. Housed in two motels with 362 rooms, the center provides people concerned that they could infect elderly or medically vulnerable family members a free, out-of-home option for shelter.
Iñaki Rezola, operations section chief for Hillsborough’s emergency management team, said that while the center’s main goal is to help people at the beginning of infection — when they are typically shedding the most virus and pose the biggest risk — it is also accepting patients discharged from hospitals.
Rezola said 14 people have already checked in. Referrals for a spot are made by physicians to the county’s department of health.
Rezola said guests (he emphasized that they are not patients) are served three meals a day in their rooms, paid for by the county. While no medical workers are on site, the staff is available to deliver medicine and has access to doctors via telemedicine. Each unit has its own air conditioning and heating, so there is little concern of contamination from adjacent rooms.
“Placement is voluntary,” Rezola said. “You choose to go here. No one is being kept against their will.”
On Wednesday, North Carolina announced that it had secured 16,500 hotel and dorm rooms to be used as recovery centers for those who have recently left the hospital and are possibly still infectious, and, separately, for what the state calls “shelter-in-peace” sites for first responders such as doctors, nurses and police.
The recovery centers will provide medical support such as supplemental oxygen. The “shelter-in-peace” buildings will have reconfigured HVAC systems so that rooms don’t share air; after each room is vacated, it will be sterilized with 135-degree heat for three hours to kill any virus on surfaces, officials said.
Two funerals, three deaths
Marcos Melendez wishes that such facilities existed a few weeks ago near his home in West Jordan, Utah. A Costco cashier, Melendez said he believes he was the first in his family to become infected.
The second week of March, he said, he came down with a high fever and a cough so bad that he contacted his doctor at the University of Utah via video chat. He said he was told to quarantine for 14 days and call back if he got worse. It wasn’t long before the rest of his household — his wife; two sons, ages 22 and 28; and 24-year-old daughter Silvia — were infected.
“I was surprised they didn’t take me to the hospital. I should have gone to the hospital, and I should have stayed in the hospital so I didn’t infect my family,” Melendez said.
As he feared, Silvia, who a few years ago underwent open-heart surgery because of a genetic condition, became seriously ill. What he didn’t expect was that his wife would, too. Both were admitted to the hospital. His wife pulled through and is at home recovering. Silvia died on March 28.
On Friday, Sandy Brown buried her husband and her only son in a cemetery near their hometown of Grand Blanc, Mich. She recalled Freddie Brown Jr. as a gentleman who always opened the door for her and “dressed to the nines.” Her son, Freddie Brown III, or “Sonny,” was a defensive lineman for his high school football team and had planned to study kinesthesiology at Michigan State in the fall.
Just hours after her husband’s death on March 26, Brown said, her son suddenly developed a 102.8-degree fever and was having difficulty breathing.
“I know he got it from his dad. He was fine before,” she said.
Three days later, she was on FaceTime with Sonny at the hospital as medical workers were about to put him on a ventilator.
“I told him to stay calm. He was afraid. His dad died on the same floor. I begged them to be able to be in the room with him,” she said. The doctors refused because of the risk of infection, but a few hours later she got a call telling her to hurry to the hospital. By the time she arrived, he was gone.
“This is a horrible disease,” she said, “a horrible plague. And that’s the story.”
Alice Crites in Washington and Liu Yang in Beijing contributed to this report.