Nurse’s ordeal reveals uncoordinated state, federal Ebola policies

The first public protests by a U.S. citizen forcibly quarantined over Ebola fears has highlighted how politics is complicating the response of state and federal authorities to the deadly virus, say public health experts and civil rights advocates.

For travelers entering the United States from West Africa, the Centers for Disease Control and Prevention (CDC) described a conflicting system in which states are free to exceed federal recommendations on restrictions.

Among the biggest problems is that each state imposes its own rules, set by state lawmakers. The result has been a sometimes clashing mesh of rules that have landed healthy people who have committed no crime in the custody of local officials.

“We don’t have the authority to tell the states what to do when travelers end up in their states,” said CDC spokesman Benjamin Hayes. “We set the base guidelines, and the states have the choice to tighten those guidelines.”

Currently, travelers who have been to any of the three West African countries hit hardest by Ebola — Sierra Leone, Liberia and Guinea — face questioning by U.S. Customs and Border Protection (CBP) when they fly out of those countries’ airports, Hayes said. CBP prevents anyone who exhibits Ebola symptoms from boarding planes.

Travelers go through the process again when they arrive at one of five airports designated to screen them in the U.S.: Washington Dulles, Hartsfield-Jackson Atlanta, Newark in New Jersey, John F. Kennedy in New York City and O’Hare in Chicago. However, the CDC’s guidelines are not binding, and local and state officials are free to accept or reject the restrictions or impose stricter ones.

Kaci Hickox, the American protesting her quarantined state, entered the U.S. on Friday through Newark International Airport without any problems but wound up in the custody of New Jersey state health officials.

Although she tested negative for the Ebola virus, state health officials imposed a mandatory quarantine for Hickox, who returned from Sierra Leone, where she volunteered as a nurse with Doctors Without Borders. Her forehead registered a slightly elevated temperature on the night of her arrival, but she said it was because her face was flushed from her treatment; her oral temperature was normal. 

From Hickox’s account, her treatment at Newark airport amounted to a “frenzy of disorganization.”

“No one seemed to be in charge,” she wrote in a dispatch from her quarantine tent that The Dallas Morning News published Saturday. “No one would tell me what was going on or what would happen to me.” She said she planned to file a federal lawsuit to challenge her detention.

New Jersey Gov. Chris Christie put in place a 21-day quarantine Friday on all returning health care workers, and New York Gov. Andrew Cuomo imposed similar orders. If possible, the governors said, they would like to see the health care workers confined to their homes but would prepare facilities elsewhere if they live out of state. 

Connecticut, Florida, Maryland and Illinois have enacted similar three-week quarantine rules. Eight people in Connecticut are currently under mandatory quarantine, after having traveled to West Africa. None of them have symptoms, CBS reported. 

Federal officials cried foul on Sunday morning talk shows, calling the quarantine on Hickox medically unnecessary and discouraging to other medics who could help fight the disease, which has already claimed at least 5,000 lives in West Africa and one person, a Liberian, in the United States.

“We need those health care workers, so we do not want to put them in a position where it makes it very, very uncomfortable for them to even volunteer to go," said Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases.

On Monday, Christie allowed Hickox to travel by private carrier to her home state of Maine, where public health authorities will be responsible for her monitoring.

"All known travelers returning from West Africa to Maine are cooperating with state health officials at this time," the Maine Department of Health and Human Services said in statement late Monday, declining to provide further details. 

Later that day, the CDC announced a tiered system to evaluate the risk of travelers, including health care workers, arriving from the region. The agency recommends close monitoring for people who have had direct exposure to patients or corpses there, with less scrutiny for other travelers. 

Some U.S. citizens have little choice but to obey such orders. The U.S. military, aiding in the international response to the outbreak in West Africa, has imposed a mandatory 21-day monitoring period for all troops after they rotate out of the humanitarian posting.

The New Jersey branch of the American Civil Liberties Union hailed Hickox’s release, but slammed the state’s quarantine policy as “overbroad” and said the “government’s response should be driven by science and facts, not fear and politics.”

“I think the politicians panicked, and they became frightened that something might happen that might cost them an election,” said George Annas, a bioethicist at Boston University.  

Annas recommended the system officials put in place in Dallas, where health care workers who had treated the three Ebola patients in that city signed an agreement with public health authorities saying they'd stay off public transport and away from large crowds and submit to monitoring of their body temperature and health. 

“There’s no scientific or medical basis for the mandatory quarantines,” Annas added, saying that the process must become more consistent and governed by federal health authorities, especially at international borders.

“They should certainly take over what’s happening at the international airports,” Annas said. “That should all be the same. Whatever the policy is, it should be the same. And there shouldn’t be a mandatory quarantine for someone with no symptoms.”

The hemorrhagic virus starts off as a slight fever and then progresses over days into an deadly and excruciating breakdown of a sufferers' internal organs as their body expels streams of highly infectious vomit and diarrhea, sometimes even leaking Ebola-laden blood from numerous body opening.

The specter of the disease has inspired anxiety, but scientists insist those who have caught the disease are not contagious until they start showing symptoms.

Christie and Cuomo’s decision on quarantines came after the diagnosis Wednesday of Ebola in a returned MSF doctor, Craig Spencer, 33, now isolated and undergoing treatment at Bellevue Hospital in Manhattan. His fiancée is under mandatory quarantine at their Harlem apartment.

“People are concerned that they are going to be quarantined and they’re going to be voiceless and clueless,” said lawyer Joel Kupferman, executive director at the New York Environmental Law and Justice Project, who stressed that politicians must listen to the recommendations of medical professionals and make every effort to make quarantined individuals comfortable.

In what Annas at Boston University called a first for quarantines, Hickox managed to broadcast her discontent, contacting multiple news outlets and took photos to show her spartan conditions: an outdoor tent with a medical-bed at Newark University Hospital with a chemical toilet and no shower.

“Our preference always is to have people quarantined in their homes,” Christie said Monday, defending his decision to keep Hickox under detention and acknowledging "no one ever wants to be in the hospital"

"But, the fact is I have a much greater, bigger responsibility to the people of the public," Christie said. "So, I think when she has time to reflect, she’ll understand that, as well." 

Boston University's Annas warned that Africans from Ebola-stricken lands would likely fare far worse at American borders than U.S. passport holders.

"You’re not going to get home quarantine for people who don’t have homes here," he said, adding that the public's paranoia puts those travellers at greater risk.

“The more we exaggerate how contagious Ebola is, the more likely it is that someone from Africa is going to be treated worse than other people. And that’s bad.”