To Quarantine Or Not to Quarantine

As you may know, there is a brewing controversy over what to do with healthcare workers returning from the Ebola hot zone in West Africa. After Craig Spencer came down with Ebola, several governors imposed quarantines on returning healthcare workers. Controversy erupted and, I believe, we are down to home quarantine for 21 days.

A few thoughts:

First, it’s true that there has been a bit of an over-reaction. So far, we have only had two people infected while in this country and both of them were healthcare workers taking care of a dying man without adequate protection. Naturally, we need to be vigilant. The virus is unlikely to mutate to become airborne but it may mutate to become far more infectious. As Nobel Prize winner Bruce Beutler has noted, we don’t have as much information as we’d like about how infectious this strain is. But, even with those caveats, the policies being advocated in some quarters are unwarranted at this stage.1

Second, the most important thing about fighting Ebola is stomping it out in Africa. If we do not stop Ebola in Africa, it will spread. It will spread to bigger cities. It will spread to other countries. Right now, we only have to worry about people who have actually been in West Africa. If this goes on and blows up to hundreds of thousands of cases or millions, we will have to worry about everyone. A house in our neighborhood is on fire. We’ve had a few cinders land on our roof. But the most important thing is not that we spray water on our roof; it’s that we put out the fire before the whole neighborhood is ablaze.

Anything that discourages healthcare workers from going to West Africa to fight this thing is likely to make things worse. Quarantine sounds like an easy burden to impose. But, in The Hot Zone, Richard Preston describes the psychological trauma that quarantine imposes on workers at USAMRIID. This is not a light burden. And isolating them in hospitals is a good recipe for getting them sick with the opportunistic diseases that infest every hospital in the world.

That having been said, it’s not irrational to be afraid of this disease. It’s not irrational to think that healthcare workers — who are the most at risk and who have close contact with dozens of people very day — should back off until they are clear. We have been very lucky so far that this hasn’t erupted in a school or something. We’ve been very lucky that infected people have sought help immediately. We have been very lucky that this hasn’t mutated to be much more infectious. All it takes is one idiot to wait until he literally drops dead in the street for this to become a serious serious problem. All the reassurances about how we can contain this are going to be cold comfort to someone who gets infected by a returning healthcare worker.

The dilemma is that treating potential victims like pariahs increases the odds of that nightmare scenario. It encourages them to hide their symptoms and to lie. So what do we do?

To me, these problems are interlocked: getting more healthcare workers to West Africa and keeping them from spreading the disease when they return are the same problem. So here is what I would propose:

  • Healthcare workers who go to West Africa should be guaranteed early spots in the line for experimental drugs like ZMAPP. These drugs are difficult to produce and will come online in small quantities (you can read a great summary of this from the aforementioned Preston). The biggest worry healthcare workers have about Ebola is not that they will lose their jobs; it’s that they will die. Promise them that they will get the best possible care. They deserve it.
  • Congress should authorize a fund to give hazard pay to healthcare workers who volunteer to fight Ebola in West Africa. We have to be careful here to not undermine the volunteer organizations that are the frontline for these epidemics. But they are being overwhelmed. They desperately need reinforcements. This fund would also pay for healthcare, life insurance and maintaining their existing jobs. This in addition to the funds needed to provide medical equipment for them to work with.
  • This fund would will also pay volunteers to undergo a three-week home quarantine on their return, during which they will be monitored for symptoms and maintain a log of any contacts.
  • We have laws that protect military reservists from being financially or legally ruined when they are called up to active duty during a war. Extend those laws to healthcare workers who volunteer to fight Ebola or are in quarantine after their return.
  • If we are going to go to war with Ebola, we have to treat it like a war. Doctors and nurses are our soldiers in this war. Pay them, reward them, protect them. Treat them in a manner that is good for public safety but also recognizes the tremendous risks they are taking and the tremendous good they are doing. Whatever else one may think of Craig Spencer or Kaci Hickox, they have risked their lives to try to save people, most of whom are a different nationality and race from them. Let’s recognize that even as we move to secure our public health.


    1. Of course, the same media telling us we are over-reacting were also saying Ebola would never come here in the first place.

    Blaming Republicans Again

    I know you thought that the current Ebola outbreak was the result of dysfunctional countries with horrendous health care systems. Or maybe you thought it was the fault of organizations like the WHO to respond quickly enough. Or maybe you think it’s no one’s fault and that disease outbreaks are going to happen.

    But you’re wrong. The current Ebola outbreak is the fault of …. Republicans:

    “Republican Cuts Kill” is the message coming from The Agenda Project, a 501(c)4 organization that is placing ads in various battleground states. According to an email signed by the group’s founder Erica Payne and titled “If you die, blame them,” the group is starting a

    a multi-pronged blitzkrieg attack that lays blame for the Ebola crisis exactly where it belongs– at the feet of the Republican lawmakers. Like rabid dogs in a butcher shop, Republicans have indiscriminately shredded everything in their path, including critical programs that could have dealt with the Ebola crisis before it reached our country.

    The supposed proximate cause is “deep draconian cuts” in the budgets of the NIH and the CDC which hindered their disease response. Never mind that the US still spends a total of $8 billion on global health. Never mind that the CDC and NIH have nearly $40 billion in funding between them. Never mind that cuts to CDC/NIH and specifically cuts for disease control were included in the budget proposal of Barack Obama who, last time I checked, was not a Republican. Never mind that according to Daily Kos’s own graph, the steep budget cuts in PHEP started in 2006, when the Democrats controlled Congress. Never mind that the Republican increased CDC funding over the President’s budget.

    Conservatives, dammit!

    This was partially stimulated by the head of the NIH saying that we would have an Ebola vaccine if not for budget cuts. Numerous people have responded by finding silliness in the NIH budget — such as $666,000 grant to find out why people like watching Seinfeld reruns — that they did have money for. I’m a bit loathe to play that game because often projects that sound stupid aren’t or are, at least, massively misrepresented.

    But I will take issue with the NIH’s claim that we’d have an Ebola vaccine if it weren’t for budget cuts (a claim they are slowly backing away from). Vaccine research is hard. We’ve been spoiled because most of the vaccines we’re used to — like measles — are cheap, effective and have minimal side effects. Such vaccines have wiped out smallpox and brought polio to the brink of extinction. But not all vaccines are that easy. We’ve been working on an AIDS vaccine for thirty years. Enormous effort has gone into finding a vaccine for malaria — which kills hundreds of thousands of people a year — with no success. Even some of the vaccines we do have are hideously expensive, come with significant side effects or have limited effectiveness. NIH might have an Ebola vaccine if they had more money. They might also have nothing.

    I’m a big fan of science funding, obviously. I like NIH to be well-funded. Public health is one of the few things we can all agree government should invest in. And I think basic science funding falls under Adam Smith’s description of something “which it can never be for the interest of any individual, or small number of individuals, to erect and maintain” but that benefits the public generally. But Ebola is not the reason to fund the NIH. They should be funded because of the outstanding research they do on everything else, especially the chronic common diseases that affect all of us. I especially want them to be working on antibiotic-resistant diseases, which, to my mind, pose the greatest healthcare menace for the 21st century. They should research Ebola as well. With a $30 billion budget, there’s plenty to go around. But Ebola research is only a tiny fraction of what they do. And I’d prefer they not try to pretend otherwise.

    As for the CDC, a bit less money on public health issues and a bit more money on infectious disease would be a good idea. And that, my friends, is squarely on the President and the man he appointed to head that agency.

    As a general rule, however, I would prefer that we keep Ebola and politics apart. This isn’t an excuse to grind your favorite political axe, be it immigration, budget cuts or single-payer healthcare. This is a time to calmly but decisively react to a potential health crisis. The main effort should be stomp this out in West Africa before it really does rage out of control. Because if this blows up to hundreds of thousands of people, if this spreads to South Africa or India or China, we will have a global epidemic on our hands.

    Planned Parenthood’s War on Women

    Over the last few weeks, a number of prominent Republicans have come out in favor of making the birth control pill available over the counter. This action has the support of the American Society of Obstetric and Gynecology. It would almost certainly bring prices down and obviate the need for women to make an expensive visit to the OB/Gyn to get birth control. It wouldn’t end the Culture War, but it would turn down the heat a bit.

    There are reasons to be concerned: the “standard” pill isn’t appropriate for everyone and the wrong prescription can create serious health problems (a friend of mine developed a pulmonary embolism because of a bad scrip). But opposition is also coming from an unexpected source: Planned Parenthood.

    Planned Parenthood opposes over-the-counter contraception, pushing back against a popular Republican argument being used in many Senate races this year.

    The nonprofit’s lobbying arm, which advocates for women’s reproductive health issues, argued that calls for allowing birth control pills to be sold without a prescription are “empty gestures.”

    The policy change would “force women to go back to the days when they paid out of pocket for birth control — which can cost upwards of $600 a year,” Planned Parenthood Action Fund wrote on its website.

    As has been pointed out, there are stores that sell birth control bills for as little as $10-20 a month. Furthermore, there is no power on Earth that can stop an insurer from covering birth control even if it is over-the-counter. In fact, there’s no reason the birth control mandate can not include reimbursement for OTC birth control (said mandate having been upheld for all but religious organizations and closely-held corporations). Going even further, the contraception mandate was justified by its supporters because some women need very specialized birth control or IUD devices. These would not be available over-the-counter as Planned Parenthood notes in their own statement. Nothing in this would destroy the Obamacare mandate. Nothing in this would stop women from getting birth control. All it would do is change how they get it.

    Then there’s this gem:

    The statement also noted that no prescription drug manufacturer has applied for their pills to be made available over the counter.

    As one of my Twitter followers noted, spot the paradox! We can’t make it available over the counter because no one is asking for permission to sell over the counter this thing they legally can’t sell over the counter.

    Of course, I’m sure this has nothing to do with Planned Parenthood themselves being a vendor of reproductive services and prescription birth control. Nothing whatsoever. And I’m sure it has nothing to do with the money they get from the federal government and state governments to provide birth control to poor women. And I’m sure it has nothing to do with their political arm wanting to maintain a “war on women” to raise money and campaign against Republicans. God forbid we should defuse that particular line of crap.

    It’s funny. Planned Parenthood is an organization I agree with on a number of issues. But the way they approach the issues fills me with revulsion. They are stewed in Culture War rhetoric and a deep hatred of everything Republican. In this case, it has massively warped their vision. Making birth control available over the counter would do a lot to increase women’s access (especially for those who are uninsured). Planned Parenthood’s position is that they oppose it because REPUBLICANS.

    If there’s a War on Women, Planned Parenthood is shooting at their own side.

    Going Dark For A Week

    So I’m off to the Land of the Big Sky tomorrow, heading out to Montana to visit some relatives. I will also be spending some time seeing Yellowstone and other national treasures before Obama leaves us all completely skint. That means I’ll go mostly dark for the next ten days: few if any posts or tweets. What little time I have for computers is going to be spent writing.

    The one topic I did not get into but wanted to was the growing crisis at our border. I can only say that I agree with a of what Doug Mataconis says here. This is not a club for the parties to beat each other with over the issue of illegal immigration. This is a refugee crisis: parents sending their children to America in the desperate hope of avoiding a growing horror of drug violence in Honduras, Guatemala and Nicaragua. Most of these people are showing at border checkpoints and asking for asylum, not trying to sneak in. These are minors faced with the choice of joining in the violence or being a victim of it. There are no easy solutions to this. We simply can’t open our borders to hundreds of thousands of minors.

    The situation has has been exacerbated, as bad situations usually are, by idiotic laws. In this case a Bush-era law that, in an effort to combat human trafficking, decreed that unaccompanied minors could not just simply be sent back; and an Obama-era law that was targeted at Mexican children but has given Central Americans the impression that children can easily get asylum here. Those laws needs to be changed and more resources need to devoted to the problem. Our border patrol are simply overwhelmed. But I expect nothing to be done because Congress and the President would rather argue about unrelated issues.

    While I’m away, I expect the usual week from our political system: Obama will screw up again or some scandal news will emerge so that the MSM can ignore it; any good economic news will be attributed to Obama while bad news will be blamed on “austerity”; any setback in the Culture Wars — no matter what — will be attributed to the Hobby Lobby decision. Paul Krugman will say something smug and dumb. And Vox will there to Voxsplain how we really don’t understand the issues anyway.

    Such is life in the political blogosphere. It will be good to have a week to clean out my mental spark plugs.

    Day After Thoughts on Hobby Lobby

    So I’ve had a few days to digest the Hobby Lobby decision and wanted to put up some further thoughts.

    First, a lot of Leftists are claiming that this decision “proves” that we need single payer to make all these issues go away. Of course, the Left saw yesterday’s World Cup game as proof we need single payer. But the argument from the Hobby Lobby case is so poor that even Ezra Klein sees right through it:

    At the core of the case is the fact that Obamacare had to decide which health-care services absolutely needed to be covered and which services didn’t. One of the services Obamacare deemed essential was contraception. That’s what led to the Hobby Lobby case: prior to Obamacare, there was no federal law forcing employers who offered insurance to cover contraceptive care, and so no need for employers to seek exemptions to that law.

    A single-payer system heightens the stakes on this kind of decision. The assumption behind some of the Hobby Lobby-based arguments for single payer is that a single-payer system would cover contraception and that would mean everyone’s insurance covers contraception. But a Republican-led government could decide that taxpayer dollars shouldn’t be going to cover contraception at all, and then a single-payer system means no one’s insurance covers contraception.

    An example comes from one America’s current single-payer systems: Medicaid. While Medicaid does cover contraception, Congress decreed years ago that it can’t, under any circumstances, pay for abortions. So while people buying private insurance can choose a plan that covers abortion if they want (and, in fact, about two-thirds of private health-insurance plans cover abortions), people in the Medicaid system have no option to choose a plan that covers abortion.

    Ding! It boggles my mind that people can claim single payer will “take the politics” out of healthcare decisions. I have to believe that the “this supports single payer” claimants really mean something else: with single payer, Obama will be able to force a liberal vision of health insurance on the rest of the nation. That’s fine … as long as he’s President. But what will they say when President Santorum strips out birth control coverage and mandates coverage for gay conversion therapy? This is what conservatives and libertarians warned about from day one: the further you involve the government in healthcare, the more politicized healthcare decisions will become.

    I oppose encroachments of government power. I oppose them even when I like the guy in office. The reason, as Lee pointed out endlessly, is because I know that he will not be in office forever. Eventually, someone I don’t like will be in. And he’ll have all the power we gave the last guy and take even more. See: Obama, Barack and Surveillance State.

    Second, I am amazed at just how silly some of the commentary has gotten. Many commentators have clearly not read the decision or even vaguely familiar with its contents. Megan McArdle deals with some of the silliest talking points here. Eugene Volokh explains the narrowness of the ruling and why it was a statutory not Constitutional decision here. I’m hoping Ann Althouse, who has read the entire decision and is an expert on Constitutional Law and religion, will do some more blog posts on it. One of her first posts is this one, taking on the talking point that businesses can now do anything if they say it’s in the name of religion:

    Under the Religious Freedom Restoration Act, when the federal government imposes a substantial burden on the exercise of religion, it must justify that burden by showing that it is the least restrictive means of achieving a compelling governmental interest. In Hobby Lobby, the compelling governmental interest is comprehensive preventive health care for women, and the majority said that requiring the employer to include coverage of all FDA-approved contraceptives in its health care plan was not the least restrictive way to to serve that interest. There are other ways the government could get the cost of contraceptives covered, ways that wouldn’t rope in the employer.

    So the government’s interest could be served without imposing the burden on religion.

    But when the government bans race discrimination, it is serving a compelling interest in banning race discrimination and there is no alternative way to achieve that end.

    Exactly. The RFRA is designed to apply a common-sense limitation on government action where religion is concerned. It’s not a blanket that can allow human sacrifice or a refusal to pay taxes. In this particular case, the Court decided that the government can make sure women have access to birth control without requiring religious people to compromise their beliefs. And that was all it could rule on at this time.

    Importantly, the Court did not decree that “corporations are people” or give them First Amendment rights (although they do have First Amendment rights in the context of free speech). They ruled that the people running closely-held businesses have First Amendment rights and that the RFRA requires the government to respect that. Don’t like it? All you have to do is revise the RFRA. Good luck with that.

    Third, what’s amazing about the commentary is the number of catch-22’s the liberal intelligentsia places the Court in. When the Court ruled that birth control coverage could be refused for religious reasons, they started screaming, “Well, what about blood transfusions! What about psychiatry? What about gelatin? Huh? Huh? Huh?” But when the Court declined to specifically address those issues — because they can’t — the liberals then accused the Court of foisting their own religion on the country and ignoring everyone else’s.

    They accused the Court of scientific illiteracy when they ruled on the methods Hobby Lobby believes are abortifacients (although, having poked around, I don’t the case that they aren’t is as ironclad as claimed). But when the Court clarified that coverage for all methods of contraception could be declined, they went ape again that the ruling was overly broad.

    (I also must keep harping on this point: insurance-provided birth control is not “free”. You pay for it with your work. And you pay for it specifically with money your boss gives to the insurance company instead of you. Mother Jones — always a good source of mathematical garbage — put up a calculator showing how much birth control will cost a woman over her reproductive life. But she’s going to pay that price whether she is insured or not. In fact, there are good reasons to believe she will pay more by getting it through her insurance. What happens is that people get birth control through their employer’s insurance … and then wonder why their insurance premiums went up $50 a month.)

    The one idea I keep returning to, however, is this: the Left should not be angry. Miffed a bit, sure. But they shouldn’t really be angry.

    They should be ecstatic.

    We now live in a country where insurance coverage of contraception is mandated by law for all but a small segment of employers. And those will almost certainly be covered when Obama expands the compromise that the Court gave their assent to (although he will probably let women swing in the wind until after the election). The conservative wing of the Court did not dispute that the government can provide birth control coverage. Nor did they dispute that insuring women have access to birth control was a compelling interest of the government. Griswold is in no danger of being repealed. A slight wrinkle has been thrown out in how birth control is paid for. And there are some states where Republicans are attacking programs that help pay for birth control for poor women. But overall, women are in a far better position with respect to controlling their reproductive systems than they have ever been.

    I know people want to see this in terms of absolutes: that women have an absolute right to birth control. But living in a country of 300 million people means none of us get everything we want. There are no absolute policies that will work for the entire country.

    And yet, with a near complete victory — the provision of almost “free” birth control; a goal they have wanted for decades — they are in hysterics because it wasn’t a complete victory. They are angry because a compromise was reached for people who have a moral objection to certain types of birth control. They are angry because they didn’t get everything they wanted. 85% of employers covered birth control before Obamacare. Nearly 100% will now and the remainder will get it through some kind of compromise. You can be a bit disappointed that it’s not 100%. But proclaiming that SCOTUS has now imposed Sharia Law and made women second-class citizens? Seriously?

    Damon Linker:

    Where once the religious right sought to inject a unified ideology of traditionalist Judeo-Christianity into the nation’s politics, now it seeks merely to protect itself against a newly aggressive form of secular social liberalism. Sometimes that liberalism takes the relatively benign and amorphous form of an irreverent, sex-obsessed popular culture and public opinion that is unsympathetic to claims of religious truth. But at other times, it comes backed up by the coercive powers of government.

    That’s how the Hobby Lobby case needs to be understood: as a defensive response to the government attempting to regulate areas of life that it never previously sought to control. Like, for instance, the precise range of health insurance benefits a business must provide to its employees under penalty of law. Hobby Lobby doesn’t oppose contraception as such, as some Catholic businesses do. It merely opposes four out of 20 forms of contraception that the Obama administration wants to force them to cover — because its owners believe those four to be abortifacients.

    From advancing an ideological project to transform America into an explicitly Catholic-Christian nation to asking that a business run by devout Christians be given a partial exemption from a government regulation that would force it to violate its beliefs — that’s what the religious right has been reduced to in just 10 years.

    Exactly. The Left Wing has been running up victory after victory in the Culture War. Gay marriage just became legal in fricking Kentucky. Colleges are so eager to make birth control available, they’ll shove it down throat if you sleep with your mouth open. Marijuana is legal in two states and the edifice of criminalization is imploding. Public prayer has been reduced to few non-denominational utterances. Their only conservative “wins” have been a few recent restrictions on abortion and public funding for birth control, policy changes that are likely to be short-lived.

    For a long time the Left has claimed that they are the side that wants to compromise and it is conservatives who are intransigent. Yet what is this but rejecting a compromise? What is this but going to tired “war on women” rhetoric at the slightest provocation? No one is being denied birth control. No one’s boss is interfering with their birth control. This is ultimate result of the Hobby Lobby decision: the Federal government will have to make a deal to provide birth control coverage for employees of a small fraction of businesses..

    That’s a War on Women? That’s treating corporations like people and women like second-class citizens?

    I humbly suggest the rhetoric over this decision needs to be toned down. Because if the Left shout down the heavens for something like this, who’s going to be listening when a state tries to outlaw abortion? Or repeal sexual discrimination laws? Or place heavy restrictions on birth control?

    When it comes to long political struggles, you have to choose your battlefields. As much as I oppose much of what the religious right is doing right now, this isn’t the field on which the banners should be unfurled. Accept the near complete victory and move on.