“Doctor, I tried to sleep on the couch in my living room; then I tried to sleep in my son’s room; and then I just could not breathe,” a 39-year-old female patient of mine told me last week. Then, through labored gasps and coughs inches from my face, she confessed her gravest fear: “I don’t want to infect my family.” She was a nursing assistant who had been infected on the job, and while she had done her best to self-isolate at home, she came to the hospital not just because her condition was deteriorating, but because she thought protecting family members had become impossible.
My patient was right to be concerned: Home isolation is nearly impossible for many patients – an underappreciated factor in the spread of covid-19. Many of my patients recently have been infected by family members who were already sick, despite their best efforts to stay more than six feet apart, wash their hands, wear masks and clean surfaces regularly. When I called the sister of a patient for more history about how she had gotten sick, the response was, “Which sister?” All of my interlocutor’s sisters had been admitted to the hospital that same week. They all lived together, and only she remained uninfected. In treating some patients, I’ve seen an entire family become infected over the course of several days, leaving no one healthy enough to help the others.
As a doctor, I’ve concluded I cannot in good conscience send covid-19 patients who don’t warrant admission to the hospital back home, if they live with other people. For such patients, we urgently need more large-scale facilities where people can recover in genuine isolation. Such sites are equally important for the isolation of those patients who have been admitted to the hospital and discharged – but aren’t yet fully recovered. They could also likely help patients who have covid-19 symptoms but whose doctors tell them to stay home until things get worse.
If we can fix the home isolation conundrum, we will have solved a notable challenge in this outbreak.
In Massachusetts, where I work, we are fortunate to have Boston Hope, in effect a field hospital in what was previously the Boston Convention and Exhibition Center. It has been repurposed into a 1,000-bed facility for those who are covid-19 positive but do not require acute hospitalization. (Five hundred beds are reserved for covid-positive homeless people.) I have begun sending some of my covid-19 patients who I doubt can safely isolate at home there straight from the ER. But it’s up to individual doctors to make that call. The determination should hinge on each individual’s living conditions, about which doctors need to carefully inquire.
Consider how challenging isolating at home is. To be able to pull it off, you really need a separate room and bathroom – a luxury afforded to few – and must be able to care for yourself without significant interaction with others (which is tough when you can hardly catch your own breath). Data suggest that rooms quickly become infected with viral particles, which affix themselves to everything from door handles to toilet seats. Moreover, recent studies suggest that air-conditioning systems likely spread droplets all around rooms. Decontamination works, but that process puts the person cleaning the room at risk. Done properly, it requires personal protective equipment, which has been hard enough to obtain for front-line health-care workers.
If there are family members in high-risk groups, such as grandparents or those with compromised immune systems, failed self-isolation can be deadly.
Many health-care workers, as we know, should also not be living with other people, especially since it is likely that you can transmit covid-19 before you exhibit symptoms. Many have removed themselves from their families; some have even slept in their cars. (I myself am fortunate to live alone in a studio.) Companies such as Airbnb have offered first responders and health-care workers places to stay, as have some colleges, but too many people cling to the unrealistic goal of at-home isolation.
We should have foreseen this. We knew from early findings out of China, notably the WHO-China Joint Mission report, that family clusters were large drivers of the outbreak. Because of this, the Wuhan response emphasized isolating the sick outside the home. There, gymnasiums and stadiums up to 1,000 beds in size were used for isolating mild cases; they were called “cabin hospitals.” As Singapore experiences a resurgence of cases, officials there are also establishing isolation centers.
Some critics of this approach have warned against the separation of families – especially of parents from children. These are important considerations, and non-home isolation may ultimately not be feasible for some people (such as those with young children and no other family support). There are good reasons to not force this policy upon people.
But we should give patients the option to isolate away from their homes, encourage them to do so and support them. Isolation facilities might be especially important for people lacking stable housing, as well as low-income patients who live in crowded houses. Such people, we know, are already disproportionately hurt by the pandemic. Even if we only get some patients into central isolation centers, that would blunt transmission of the coronavirus.
More efforts along the lines of Boston Hope are needed throughout the country. There’s some movement in this direction, but not nearly enough. New York has spent $250 million to contract with hotels to house people discharged from hospitals, for example, and both New York and San Francisco are isolating homeless people who were previously in shelters.
It’s crucial, when the disease first strikes, to get people out of their houses or apartments as quickly as possible – and important to keep them out of their homes as they recover. My 39-year-old female patient went from my hospital directly to Boston Hope. Both she and I can rest easier, knowing that she’s unlikely to infect her family.
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Karan is a physician at Brigham and Women’s Hospital and a clinical fellow at Harvard Medical School.