An Interview with Geoff Manaugh and Nicola Twilley

What the history of quarantine can teach us about confronting fear, risk, and uncertainty

In 2009, Geoff Manaugh and Nicola Twilley visited Sydney, Australia, and noticed a seaside hotel, called Q Station, that used to be a quarantine station. Manaugh recalls their interest in the converted hotel, and how the things that made it “such a good site for quarantining people” were also what made it an attractive place for tourists, like the remote location and open design. “Our question at the time was: What happened to this practice? Why don't we do it anymore?” Manaugh says. Once Manaugh and Twilley started to research the history of old facilities like Sydney’s, they realized that quarantine was everywhere, not only in the past, but in the present, too. “The minute you start looking into it,” Manaugh says, “you realize that quarantine is something that we still do, and at pretty much every level of society.”

That initial curiosity about quarantine led to years of research and reporting on the subject, which would eventually become Manaugh and Twilley’s fascinating 2021 book Until Proven Safe: The History and Future of Quarantine. Here, Manaugh and Twilley talk about what it was like watching the quarantines of the Covid-19 pandemic unfold, how to design a better quarantine experience, and quarantine’s lessons for dealing with uncertainty.

Kiley Bense: When the pandemic hit, you had already done so much research and reporting on the history of quarantine for this book. Were there things you learned or discovered in that process that you gained a new perspective on once you yourselves were living through a pandemic?

Nicola Twilley: The timing was really bizarre because we had done all of our reporting and research, which was great, because that took so much travel, so to do it before lockdown was ideal. Having all this information and watching a real pandemic play out in real-time was incredible. There were so many interesting moments. One of the things that we were so excited about in our research for the book was finding someone who had experienced quarantine. It was a quest, pre-Covid, to find someone who could tell us what it's like to be in quarantine. And then, of course, within a few months of 2020 starting, half the world could have told us that. We weren't trying to explain this foreign, medieval concept to people anymore. 

It was also a very frustrating experience, because so many of the mistakes that had been made in quarantines in the past, where quarantine had gone wrong, or not been thought through, or failed in some way, or been abused, we saw them happening again during Covid. It’s very frustrating to know everything we knew, and then see this all play out. I was both frustrated and amazed at how consistent the world's experience of quarantine was, historically and then during Covid.

Geoff Manaugh: The history of quarantine is also the history of resistance to quarantine. People are constantly trying to get out of it, or find a way out of it, or literally violate quarantine, or push back against it. So that was frustrating to see, but also [something] we should have seen coming when it came to Covid-19 and the lockdowns and the quarantine orders.

KB: It sounds like doing all of that reporting and research prior to the pandemic gave you a similar perspective to some of the public health officials you interviewed for this book, who had studied pandemics and prepared game plans and thought through how we should combat an emerging pandemic. In the U.S., so many of their plans were not followed, and that was an extraordinarily frustrating experience for them. 

NT: We had spent years talking to some of these people, like Marty Cetron [the CDC’s Director for the Division of Global Migration and Quarantine] or Luigi Bertinato in Italy [former director of international health for the Veneto region], before the pandemic, and then we caught up with them during the pandemic. On the phone, Marty Cetron sounded almost devastated. To have done so much work, and devoted his career to planning for this, and to reforming quarantine so that it was less unjust, and he hadn't anticipated the way in which politics would make the difference to whether you could implement the plan or not. He’d done all this research into what makes quarantines succeed or fail, into when you should implement them and how soon, how gradually, when you should start lifting restrictions, all of this data-driven research on how, and legal research on how to make it fair. But he hadn't taken into account the fact that we were in the Trump administration. If you have a plan, and you don't implement the plan, it's as good as having no plan at all. Whereas countries that he had trained using the U.S. plan, like South Korea, for example, who implemented our plan, were doing so much better. I think it was just heartbreaking for him.

KB: Looking back at both Ebola and the beginning of Covid-19, you can see how politics and fear can influence our reaction to disease much more than evidence, pushing us to overreact or to underreact. Human beings are not good at assessing risk, and quarantine itself is characterized by suspicion, and that’s one of the things that makes it so susceptible to abuse and discrimination. Is there anything that we can learn from the Ebola response (and what happened to Kaci Hickox) about how we can mitigate the abuse of quarantine in the future, to lead with evidence and not fear?

GM: There is modern evidence-based quarantine that exists today, but I think the problem with quarantine is that it is used when we don't know what else to do, especially in situations like Covid-19, where at first we didn't know how it was spread, we didn’t necessarily know its incubation period, we didn't understand what all of the symptoms were. When new diseases emerge and come to our cities or towns, or pop up where we're not expecting them to, we have to use quarantine precisely because we don't have an understanding of the threat. So I think that is a permanent problem; it’s built into quarantine. 

One answer is just better communication. It’s a very easy thing to say, and a very hard thing to implement. But we need to find a way to get the public behind the idea of uncertainty in the scientific sense, and to an understanding that uncertainty doesn't mean that we simply don't know what we're talking about, or that we’re throwing spaghetti at the wall, or we're lost in superstition. Uncertainty is not an admission of failure.

NT: Personally, I feel like this is a larger systemic problem around how science is communicated. Science progresses by reducing uncertainty rather than proclaiming truth, and I feel as though that there is a fundamental miscommunication, like Geoff says, and ultimate misunderstanding of what science is and how it works. That’s a flaw that's built into science education and science communication, I think, and that does not help people grapple with these larger issues. 

Something Marty Cetron would always say is: if you don't have trust in your officials, your experts, your leaders, you are essentially screwed. And you can't build that trust up in an emergency; you have to have built it up before the emergency. It’s not the kind of trust that is like, “Oh, these people know all the answers, and they're always right.” It’s not: we must all unthinkingly believe the scientists. No, it's the kind of trust that says these people are trying to do the right thing, they are considering the needs of the public, they will do what they say they will do in terms of their duty of care. Trust is an essential element in a pandemic response plan. And in the U.S., that was at an all-time low.

GM: What was so interesting about Kaci Hickox was the revelation of just how wrong we were with our initial impression of her story. She was presented as an incredibly negative figure in the public eye and in media coverage, as this uppity woman who wouldn't do what she was told and thought she knew better than the authorities. As it happened, she did know better than the authorities. Ironically, her pushing back against quarantine, I think, helped refine the power and bring attention to its limitations. Her lawsuit against Chris Christie has some tangible benefits for other people, so I think it's always worth remembering that sometimes pushing back against things that appear arbitrary really can make things better for others, and it isn't necessarily just being impetuous or difficult.

KB: I have thought a lot about the quote that you include from the judge who decided Kaci Hickox’s case, where he said, about others’ fear of her possibly being infectious: “whether the fear is rational or not, it is present and it is real.” He acknowledges that she's right, that she shouldn’t be in quarantine, and she doesn’t pose a danger to the public, but then he says, essentially, but it's human nature that people are going to be afraid of you, so you shouldn't leave your house. I thought that quote was so revealing of the pitfalls and problems with trying to implement quarantines.

NT: It’s just a series of endless pitfalls, and it’s really hard to get right. People think, “better safe than sorry; she should stay home.” But then, as she pointed out, if people have to do that, then they might not volunteer for Doctors Without Borders, because it adds another three weeks to your deployment. “Better safe than sorry” seems like a smart thing to say, but it’s not without cost. Cost-benefit analysis is hard, and risk is hard for people, as we talked about in the book. Mike Jacobs, the guy who runs the Ebola unit in the U.K., talked about the difference between risk and consequence. Risk management operates on really different principles than if you're thinking about consequence management. What are the consequences of Ebola escaping? They’re very different from the risk of it escaping. It’s just a really difficult topic, and it's never going to be easy, but I think there are ways to make it more thoughtful. When Kaci Hickox settled with Chris Christie, it was not for a monetary settlement, it was on the condition that New Jersey would reform its quarantine rules, and put in place straightforward guardrails. Doing that before there's a panic is really smart.

KB: In the book, you write about the health passports that became the passports that we use now, and you also visit lazarettos and quarantine stations that have been abandoned or repurposed. What do you think will be the legacy of this pandemic? What are the structures, and cultural changes, and bureaucracy that we're going to take with us into the future from Covid?

NT: The things we'll take, I think, actually are the things that we see already: a growing encroachment of private companies, and big data gathering on public health, with companies seeing this as a huge opportunity. I think giving up that health information for what feels like a more frictionless quarantine is something that is going to stick with us. I also feel like doing that in an unthought-through way just for convenience is a disaster. These companies’ motivation is profit, not public health. If the two are in conflict, profit is the goal. Ceding that territory to companies unthinkingly because it's more convenient and we don't trust central government, is both a disaster, and what I think is going to happen, and is already happening and will only increase.

GM: I agree with that, and I think that we are going to see a shift towards digitization of IDs and passes in the guise of convenience, which will change the cities that we live in, and the way in which we interact with government bodies, and will change travel. I also think the virtualization of a lot of urban services is probably now irreversible, this turn toward all the things that we now take for granted, and that have exploded in the last year, like delivery services and food deliveries. That's going to be the new economic direction for very many things.

KB: Quarantine is defined by uncertainty and unknowing, and so is living through a pandemic. People tend not to be good at grappling with uncertainty, especially when it persists for a long time. What can we learn from the history of quarantine about how to deal with uncertainty better?

GM: It’s a big question. Quarantine gives a space and a shape to what we don't know, and I think that's one of the reasons why quarantine is fascinating, because it becomes a metaphor so quickly, and it lends itself to other topics or to other fields of inquiry. Quarantine becomes a way to talk about what we don't know or don't understand. 

Back when quarantine was invented and was still being perfected in the Venetian Republic, having lazarettos and having these large, publicly funded facilities that people could see, they would spend time in, they would know people who had been sent there, helped give a sense that the authorities were actually trying to address public safety. It felt as if, this is proof that we have your back, and we're making an effort. This is a defense against the unknown, this facility on an island. It gave shape to people's fears. 

I think that one of the reasons that quarantine and lockdown were even more difficult during Covid-19 was that it was almost the opposite quarantine experience than we had in previous centuries, because it was very atomized and very individual. So you had people stuck at home, and it didn't really look like the state was doing anything to protect them, frankly, and they had friends that were maybe ignoring the mask rules or breaking quarantine or ignoring lockdown. It was a very frustrating, individual experience. 

One of the lessons from the past is that quarantine can be a thing that people see and feels more centralized—not in the sense that we have to send people to quarantine camps or other conspiratorial things, but in the sense that society uses quarantine to give shape to the unknown. That is a pretty important thing to learn from the history of pandemics. How we can apply that in the future is going to be pretty interesting politically and culturally, because I don't think that centralized quarantine facilities are necessarily high on the list of where Americans want to spend very much time. But I think that's at least one aspect of it.

NT: Where we ended up in Chapter Five and in the Epilogue was that quarantine is an unresolved experience design challenge and one that we should think about now, while we have this experience fresh in our mind. How can we create rituals, connections, a sense of process, progress, a feeling that you're contributing to something larger than you as part of the quarantine experience? As Geoff says, in the past, the lazaretto did that physically. In quarantine, you should be feeling good, the way that you feel good when you volunteer at your local soup kitchen. You should be feeling like you're doing something great for your community, and most people don't, and that’s a design challenge, to give this experience the profundity and resonance that it should have.■