Last August, only days after learning the first two Americans had contracted Ebola infection in West Africa, Mecklenburg County health officials faced a challenge: How to respond to the arrival of three healthy missionaries who had helped care for these and other Ebola patients in Liberia.
In consultation with state and federal counterparts, Mecklenburg health officials chose to “err on the side of caution” by ordering quarantines – a tool they had not used for two decades.
Public health officials maintain it was the right response given the newness of the epidemic’s impact in this country. But public records and interviews reveal that at least one of the quarantined missionaries objected strenuously, calling the action overly restrictive and unevenly applied to returning health care workers who had risked their lives to combat the epidemic in West Africa.
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Although Fankhauser didn’t complain publicly at the time, he made his objection known in private meetings with local and state health officials. He also put it in writing on the quarantine order, a public document. “I will comply with the law,” he wrote, “but would like to express that this is the most restrictive quarantine that any of our colleagues or coworkers have been subject to. I do not believe that this is necessary or just.”
He and the other healthy missionaries were required to stay on the SIM campus, away from the public, and monitor their temperatures for 21 days, until it was certain they wouldn’t develop symptoms of Ebola.
None ever got sick, and a year later, Mecklenburg health officials say their response was strict, but appropriate, to protect public health and avoid panic after the epidemic touched U.S. soil for the first time.
“I think it was the right thing to do,” said Dr. Stephen Keener, county health department medical director. “We were getting calls every day from angry citizens saying, ‘You should not let these people come to North Carolina.’”
Keener declined to say if he’d make the same decision, knowing what he knows now.
I will comply with the law, but would like to express that this is the most restrictive quarantine that any of our colleagues or coworkers have been subject to. I do not believe that this is necessary or just.
Dr. John Fankhauser, SIM missionary who returned to Charlotte from Liberia
One of Fankhauser’s concerns was that having to spend three weeks in quarantine would discourage workers from volunteering to help with the then-growing Ebola epidemic in West Africa.
A federal review of the U.S. response backs up Fankhauser’s position. Without naming names, the “Ethics and Ebola” report said some state quarantine policies were “ineffective and overly restrictive.” The February report noted that epidemics “create a climate of fear” and that health officials should be prepared for public pressure that could lead to “inappropriate deviation” from science-based measures and that returning volunteers should be afforded the “least restrictive limits that are effective.”
“It’s rarely the case, where Ebola is concerned, that a complete quarantine for healthy individuals would be the least restrictive measure,” said Nita Farahany, a Duke law professor and member of the commission that did the review.
Before last summer, the Ebola outbreak had not been a real threat to Americans, and public health authorities had little experience with it.
Mecklenburg was one of the first places to face a quarantine decision because Charlotte-based SIM operates a hospital in Liberia and sponsors missionaries, including one of the first two Americans diagnosed with Ebola, Nancy Writebol.
In late July, she and Dr. Kent Brantly of Boone-based Samaritan’s Purse were evacuated to Atlanta for treatment. They later recovered. The next step for SIM was to bring home Writebol’s husband, David, and two of its missionary doctors, Fankhauser and Debbie Eisenhut.
They said they had worn protective gear and followed protocols to prevent contracting the virus. But Mecklenburg officials, like most people in the United States, weren’t sure what to believe.
They understood that Ebola, while often deadly, is spread only by someone who is already having symptoms, such as fever, diarrhea and nausea. It is not airborne like influenza, but is spread through contact with bodily fluids, such as blood and feces.
Still, SIM said Nancy Writebol and Brantly had become ill even though they also followed safety protocols. “That just made us all a little nervous,” said Mecklenburg Health Director Marcus Plescia. “We didn’t have a good sense of how well those protocols were being followed. That’s why we were acting fairly conservative.”
Mecklenburg’s quarantine decision made news last August, but it didn’t cause a panic.
That can be attributed to the cooperation between public health officials and leaders of SIM. President Bruce Johnson said the mission group wanted to “go the extra mile” to protect its Charlotte neighbors. He notified state and local health officials before bringing the missionaries home and asked for guidance.
To the public, it appeared the healthy missionaries agreed with the quarantine and even appreciated time to decompress while camping in recreational vehicles on SIM’s quiet, 90-acre campus in south Charlotte.
But Fankhauser argued for lesser restrictions from the start. As long as they were healthy, he said they should be able to monitor themselves for symptoms and report to authorities without being restricted to a certain location.
Fankhauser was as familiar with Ebola as anyone, having been on the front lines since the outbreak began in Liberia in June 2014. He and his family moved there from California in November 2013. He helped manage SIM’s hospital, until the focus changed to Ebola.
After completing the three-week quarantine, Fankhauser returned immediately to Liberia to care for another missionary who had contracted Ebola. Then in November, needing a rest, Fankhauser came back to the SIM campus knowing he faced a second quarantine.
He had hoped to visit his mother in Washington state, but after being confined for three weeks, there wasn’t time. He and his family spent Thanksgiving in California, and he returned to Liberia, where he continues to care for Ebola patients and survivors today.
SIM President Johnson, who calls Fankhauser “one of the unsung heroes” of the Ebola crisis, had learned by November that other health care workers were facing lesser restrictions elsewhere. At his request, Johnson said Mecklenburg officials eased up, allowing Fankhauser “to go outside the county without having prior approval.”
“Initially Mecklenburg County and North Carolina were understandably more conservative and restrictive than what we found in other states,” Johnson said. “It was a really challenging time. … You had to balance public perception and public safety.”
Panic breaks out
In October, the panic Mecklenburg officials had worked to avoid broke out in New York and New Jersey.
News reports detailed the activities of Dr. Craig Spencer, a Doctors Without Borders volunteer in Guinea, who had ridden the subway, eaten in restaurants and gone bowling in Manhattan before developing symptoms of Ebola. He had monitored his temperature and, when he noticed a fever, isolated himself immediately. He got well and never infected anyone.
Reaction to that case prompted New York and New Jersey governors to impose automatic quarantines on all health care workers returning from West Africa if they had contact with Ebola patients. Some elected officials called for travel bans under the mistaken belief that anyone who had been to West Africa could spread the disease.
Soon after, Kaci Hickox, a Doctors Without Borders nurse returning from Sierra Leone, was detained for three days at Newark Liberty International Airport in New Jersey. She sparked national debate when she complained publicly about the conditions, a tent with little heat or food. She had no symptoms and could not have spread the virus.
In light of those events, Kate Mort, director of field human resources for Doctors Without Borders, said some volunteers decided not to return to the United States immediately after completing service in West Africa. To avoid “stigma and hostility,” she said they chose to spend their 21-day incubation periods in Europe.
“Our experience with Craig, despite how it was portrayed by some media, really proved that the systems we had in place were adequate,” Mort said. “We can understand that people were afraid, but I think the quarantine measures kind of fuel the fear, and it’s not actually scientifically necessary.”
Finding a balance
As U.S. hospitals and health officials gained experience with Ebola, federal guidelines and public perceptions changed. Before the first Americans were diagnosed with Ebola, travelers coming into the United States from West Africa were not screened for symptoms. Today, Mecklenburg public health nurses continue to monitor a handful of people who have returned from affected countries.
“We’ve learned a lot,” said Dr. Jeffrey Engel, a former North Carolina health director who’s now executive director of the Council of State and Territorial Epidemiologists in Atlanta. “It was all new then.”
Because SIM is based in Charlotte and had missionaries working in Liberia, North Carolina and Mecklenburg County were “first out of the gate in quarantining returning workers,” Engel said. “They were quite forward-thinking and were doing the right thing in August. We didn’t know a lot about transmission yet.”
Mecklenburg’s Keener is relieved to have avoided the “drama-filled public outcry” that occurred in other parts of the country. If faced with a similar outbreak today, he said he would again consult with state and federal officials to decide about the need for quarantine.
“There are a lot of variables that you have to take into consideration,” he said. “Dr. Fankhauser is a doctor, and he was pretty confident that he knew he hadn’t been exposed. He had taken care of Ebola patients, and he hadn’t gotten sick. But not many Americans had that perspective or that base of knowledge. … We always strive to find the right balance between protection of the public and protection of individual rights.”