Ebola quarantines: nurses' perspective

American nurses and physicians have a long history of volunteering in deadly epidemics, and typically receive warranted praise when they return to their home countries. Why is Ebola any different?

by Connie Ulrich and Julie Fairman, University of Pennsylvania School of Nursing

Published Nov. 18, 2014, 6:30 a.m. ET

The Ebola crisis in West Africa continues to rage unabated. The suffering of adults, children, and communities is unparalleled. In fact, the World Health Organization estimates that nearly 5,000 people have died, including more than

The lack of public infrastructure, including appropriate medical resources and healthcare personnel has hampered local African healthcare workers' efforts to quell the outbreak. To say that international help is desperately needed is an understatement.

American nurses and physicians have a long history of volunteering their time and talent during times of natural disasters, epidemics or other world calamities. International relief plays a significant role in providing first aid on the ground, making sure that those in need receive immediate medical care, education, or other resources. Those workers typically receive warranted praise when they return to their home countries, even when they are caring for patients with deadly diseases.

Ebola presents a different scenario.

Mandatory 21-day quarantines for individuals with known exposure to Ebola patients have been announced by several states (initially including New York, New Jersey, and Illinois) to serve the greater public good. The public's welfare and safety is indeed of utmost importance and not a trivial matter. And, there are times when public well-being takes precedence over individual rights. But decisions on required quarantines should be carefully assessed to ensure that they are based on sound evidence, transparency, and informed understanding for both the public and returning health workers.

The current scenarios are problematic for several reasons:

First, Kaci Hickox – the nurse with no symptoms of Ebola who challenged Gov. Christie's quarantine when her plane landed in New Jersey and then took her home state of Maine to court over the same issue (and won) – volunteered in Sierra Leone without prior knowledge of any mandatory confinement that would accompany her return to the United States. In fact, in the last 3 months over 50 health care workers arrived back in the U.S. after caring for Ebola patients. None without symptoms were quarantined. Two physicians were quarantined when they developed symptoms or became sick; one recovered and one died on Monday.
Second, immediate seclusion has serious implications for one's physical, psychological, and economic well-being. Those who volunteer in the humanitarian service of others should be afforded our utmost respect and care upon their return.
Third, policies that are enacted without careful, deliberative, evidence-based advanced planning tend to be perceived as political and reactionary and do little to temper fear.

Historically, health professionals have cared for patients suffering from highly infectious diseases. They have worked in quarantine situations wearing protective gear that is hot, heavy, cumbersome, and caused fatigue, often staying with their patients for days at a time. In some cases, nurses and others have themselves been quarantined following exposure. This was the case in the early 20

century for scarlet fever, typhoid, and tuberculosis.

Quarantine has many facets. Stella Goostray (a highly regarded nursing leader and director of nursing at Boston Children's Hospital in the post-World War II period) noted that, at the turn of the century, when a child was admitted to a "contagious unit" the nurse went as well. "The nurse ate and slept there … food was sent up in a dumbwaiter … we saw no one but the house officer and superintendent of nurses who peered at us through a window…."

Goostray herself developed typhoid fever when, as a new probationer, she was ordered to clean an overflowed toilet in a typhoid room before she had been instructed in safe handling of excretions. The transmission of the disease was known and an understanding of how to take precautions was part of nursing training at the time, but her exposure occurred before she had this knowledge. She returned to nurse again after many weeks of recovery and isolation, which she described as lonely and forsaken.

A nurse from Simmons College in 1915 described her experience as a typhoid victim, an infection that she acquired in a manner similar to Goostray's exposure. Several weeks before she developed a fever of 104, she had been ordered to clean up a flooded "typhoid hopper" before sterilization was complete and before she understood the principles of good handwashing or was vaccinated against the infection.

Again, the principles of spreading contagion were known, but not practiced. After the onset of her illness the nurse was quarantined at the Peter Bent Brigham Hospital in Boston, and remembered the loneliness, fevers and harshness of the slush baths – a nurse poured ice water over her (while she lay in a rubber trough, so as not to contaminate others). She lost her appetite, had severe diarrhea and vomiting, and endured a long convalescence with only a few friends.

Both of the women who contracted typhoid did go back to work as nurses. But this was not the case for other nurses and physicians. In the early 20^th century, many of those who cared for tuberculosis patients also contracted TB. They experienced another type of quarantine—after their convalescence, they were unable to find positions except in tuberculosis hospitals. No other institutions would hire them, even when their disease had been eradicated or rendered non-contagious.

Today we have better tools (both simple and complex) and resources (if they are available and used as intended) to protect health care workers. This is an important factor considering that the continued service of American medical personnel in the Ebola fight is imperative. Whether the 21-day quarantine will affect recruitment of these nurses and physicians remains to be seen. But it has the potential to victimize those who care for Ebola patients in the service of others. And, if volunteer efforts slow, we will be unable to fight the disease in Western Africa, where it originated and still poses the greatest international threat.

What we do know is that sound leadership, thoughtful dialogue, strong science, and provision of needed resources is the key to prevention today, as it has been in the past – and, ultimately, to stopping this alarming disease and calming our fears.

Connie Ulrich, PhD, RN, FAAN, is an Associate Professor of Bioethics at the University of Pennsylvania School of Nursing. Julie Fairman, PhD, RN, FAAN, is Nightingale Professor of Nursing and director of the Barbara Bates Center for the Study of the History of Nursing at Penn.