Quarantine has always been a principal weapon against epidemics: isolate ailing people so they cannot spread illness. Quarantines come in various types, however, which have different effects:
- When an individual falls ill they need to be cared for in a facility that minimizes the risk that the virus will be spread to other susceptible people. This is the medical isolation that has been the key to defeating all past Ebola outbreaks. People who are suspected of having Ebola may also be kept isolated from others until their status becomes clear. I’ll call this a precautionary quarantine. A third situation is when a contact of an Ebola patient is cautioned to stay at home, or not to travel, during the 21-day incubation period. I’ll call this a monitoring quarantine.
- When an entire neighborhood or region is blocked off, the barrier is referred to by the French term, cordon sanitaire. This may be an urban neighborhood, such as the poor West Point district of Monrovia, or an entire region, such as the remote area at the intersection of Guinea, Liberia and Sierra Leone. Or it may be a de facto cordon sanitaire imposed by the closing of borders and the discontinuance of transport links.
- It is also possible to impose a curfew that limits when people can interact outside the home, in the hope that this will reduce transmission.
- Finally, Sierra Leone has announced a nationwidewide three-day lock-down, starting September 19, during which everyone will be required to stay home so as to allow a house to house inspection for hidden Ebola patients. [AFP 9/6/14]
Medical isolation is essential and effective, though in West Africa there have been many issues:
- Some rural “red” villages either doubted that Ebola is real or feared that the doctors brought it. They forced Médecins Sans Frontières/Doctors Without Borders (“MSF”) to withdraw, and in some cases physically blocked road access — a do-it-yourself (reverse) cordon sanitaire! [NYT 7/27/14] There was no choice but to let the epidemic burn itself out in those villages. I haven’t seen a report of what happened, but it will be illuminating to eventually find out.
- Urban neighborhoods have resisted siting of Ebola care facilities nearby. Residents of the poor West Point district of Monrovia attacked and ransacked a holding facility [NYT 8/19/14], which lead to the attempted cordon sanitaire around their entire neighborhood described below.
- People who fear letting ill family members go into Ebola care facilities often try to treat them at home, hiding them from authorities. This increases the risk of infection to home caregivers as well as other family members. Concern about this issue has led Sierra Leone to declare the country-wide lock down described below.
- There aren’t enough beds in Ebola care facilities, at least in Monrovia. Medical isolation fails if there’s nowhere for people to go. It’s not clear how it will be possible to get on top of this issue since the epidemic is growing exponentially and the construction of facilities — and especially provision of trained staff — is not.
Precautionary quarantines and monitoring quarantines are also essential elements of infection control. The main problem I’ve noticed there is the issue of people breaking quarantine and subsequently infecting some or many other people. The experience of Nigeria is horrific: the outbreak started with one man who broke quarantine in Liberia to fly to Lagos, but it was spread by a series of additional quarantine breakers, one after another. See my earlier post: Arrogance and Privilege Imperil Nigeria’s Attempt to Contain Ebola
On August 1, Guinea, Liberia and Sierra Leone announced a regional cordon sanitaire, to be enforced by their military forces, around the remote area where the outbreak began. The New York Times described it as an infection-control strategy that has not been employed for a century. [NYT 8/12/14] A few days later, however, a writer in the New Republic described as “heartless but effective” a similar cordon sanitaire used in 1995 to control an Ebola outbreak in Zaire. [New Republic 8/14/14] Reuters expressed the concern that the cordon could create abandoned “plague villages.” [Reuters 8/17/14] The World Food program has been struggling to provide adequate food supplies to 1.3 million people in limited access areas, including classic quarantines as well as cordons sanitaire. [WFP 9/2/14] There has been little mention of the regional cordon sanitaire in recent weeks, perhaps because the battle in the capital cities has taken center stage. The regional cordon may simply become a dead letter if Ebola continues to spread outside it.
On August 20, Liberia imposed urban cordons sanitaire on two poor and crowded neighborhoods of Monrovia: West Point and Dolo Town. Hundreds of young men in West Point rioted, throwing rocks at police, who used tear gas and live gunfire to disperse the crowd. [SaharaReporters 8/21/14] Several residents were injured, and a 15-year-old boy died. During the closure there were many stories of evasion, including a couple who bribed a soldier $10 to get out and a man who swam around the cordon each weekday to go to work in a government office. Ten days later the West Point cordon was lifted. [NYT 8/29/14] The West Point cordon would have to be called a failure. Meanwhile Dolo Town had accepted the restriction more calmly, although grumbling was reported three weeks later about continuing to be an “Ebola Jail Town.” [AFP 9/7/14]
Liberia also imposed a nationwide curfew on August 20, from 6 pm to 9 am. [AFP 8/20/14] There has been a report that nighttime armed burglaries have increased during the curfew. [The New Dawn Liberia 9/8/14] The value of the curfew is debatable. It depends on the importance of urban transmission modes, and how many potential transmission events are prevented by keeping people home at night.
A de facto cordon sanitaire around the entire region has been developing over the past couple of months through a series of border closings and flight suspensions, along with regulations barring entry to ships that had touched at ports in the affected countries. In the past week a plea has been made for flights to continue and for borders to be opened to screened transit. It will become increasingly difficult to get necessary materiel and personnel into the affected countries if transport restrictions aren’t eased.
Most recently, Sierra Leone has announced a three-day nationwide lockdown, starting Sept. 19, during which everyone is expected to stay in their homes, with exceptions only for essential travel. During this period a house-to-house inspection will be conducted to find patients that are being hidden from the authorities. A government spokesman is quoted as saying that, “We intend to ensure that the dreaded disease is checked.” [AFP 9/6/14] MSF has expressed concern that this sort of measure will do more harm than good: “It has been our experience 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…” But the top U.N. official in Sierra Leone supported the idea. [NYT 9/6/14] My own view is that the idea is daring but a lot could go wrong:
- Households that are concealing an Ebola patient are likely to resist a thorough inspection, thus frustrating the purpose.
- Even if a household doesn’t harbor an Ebola patient, it may have some other secret that will lead it to resist inspection.
- People who are angry anyway will have three full days to sit at home and get angrier and angrier. This could burst out into violence.
- How will the inspectors distinguish people who just have malaria or colds from people who really do have Ebola?
- Will the inspectors all be wearing full protective gear, and will they be trained in procedures for putting them on and taking them off? The arrival of a moon-suited team would not be a warm and fuzzy experience, but if they aren’t protected the inspectors themselves could be the next wave of victims.
- If a lot of patients are found where will they go? I’m not sure about the situation in Sierra Leone, but in Monrovia there aren’t nearly enough beds in Ebola treatment facilities. [WSJ 9/7/14]
All that said, a desperate situation calls for desperate measures. I hope the lockdown works!