Ebola Federalism, Ctd

A reader pushes back on this post:

Just to be clear here, just because a health-care worker takes time off of work to go volunteer in West Africa in fighting Ebola doesn’t mean that the institution they work for is also volunteering their away time hours. In most cases, the worker must still have accrued enough time off to actually take the vacation in question – and the employer rarely distinguishes between hours off spent sipping martinis in the Maldives and hours off spent replacing IVs in Liberia.

And while the state might reimburse them for the lost wages, that doesn’t mean their medical employer has to welcome them back after three weeks of leaving their workplaces understaffed and their coworkers overworked to fill up the slack. Treating it like the health worker should just be happy they got 21 free days off work is a bit ignorant, and assumes that health care workers are all able to gallivant off from their workplaces. Most workplaces have penalties for taking excessive time off that go well beyond merely suspending pay during the unapproved absence, and those penalties usually include being fired.

But that’s not true here; Cuomo today reassured Ebola volunteers that their jobs will be secure – and then some:

Mr. Cuomo, speaking at an event in Staten Island, noted that the Army was instituting even more restrictive measures on their personnel working in Ebola-infested regions, denying them even contact with their families–and promised New York would duplicate the military’s policy of compensating overseas workers for their time. “If [Mr. Obama]‘s critical of the quarantine, then he has to be highly critical of the Army’s policy,” Mr. Cuomo told reporters today.

“I agree with the president, whose point is, ‘don’t discourage medical workers.’ And that’s why we’ll go the added step of actually putting together a package which I don’t think any other state has done, and which I don’t think the federal government has done.” Mr. Cuomo said he and his aides were meeting with hospitals and other medical organizations to hammer out a package that would guarantee doctors traveling to the nations of Guinea, Liberia, Sierra Leone and the Republic of the Ivory Coast–where Ebola has now killed thousands–a continued income, benefits and job security. “I don’t believe that there is a clash between getting doctors to go to West Africa and an effective quarantine. I don’t believe one is the enemy of the other.

The governor also noted how the NYC area is the most dense in the US, especially compared to a place like Nebraska, “so I don’t know if one-size-fits-all works” regarding the CDC’s nationwide standards. More on the press conference here:

Most of the doctors who go are hospital employees. They tend to be emergency room doctors that go,” the governor said. “I’m asking the hospitals, you tell me: what package I need to put together to encourage medical workers to go and to do it in cooperation with the medical community because the doctors and nurses want to make sure their job are protected when they get back.”

And the fact that Ebola volunteers tend to be ER docs in close contact with trauma patients makes Cuomo’s at-home quarantine even more sensible. Update from a reader:

How does President Obama get to criticize state governors when his Department of Defense has a more stringent policy for service members who have had no contact with ebola patients at all?  My peers and I (just getting back from Afghanistan and about ready to deploy again) were also pretty fucking upset with his poor discussion of what voluntary service to our nation is.

No discussion about this at all?  I’m glad I’m getting out of the service after over a decade. When we fight ebola with the same force we fight ISIS we have completely lost our minds.  When we use different meanings to define voluntary service in the military and in the medical field I feel like we’re leaning towards losing our soul as well.

As I told my friends earlier, I believe we are using the word science when we actually mean policy (or lack there of).

Ebola Federalism

While the federal government plays a leading role in keeping Ebola out of the US – to the extent that it’s possible – governors have the authority to come up with their own protocols for dealing with suspected patients who arrive in their states. Josh Voorhees sees a few problems with that:

Consider the rules that greet medical workers upon their arrival at one of five federally mandated points of entry. Land in New York City or Newark, and they face a mandatory 21-day quarantine, regardless of risk level. Arrive in Chicago, and they should be prepared for the same—unless, that is, they wore “protective clothing” while treating patients. Fly into Atlanta, and they can either agree to check in twice daily with health officials or be involuntarily quarantined at a “state-designated facility.” Touch down at Dulles International in Virginia, and they face the same active monitoring but without the threat of forced isolation. …

America’s governors, meanwhile, say they are just doing their jobs. “My first responsibility is to protect the public health and safety of the people of New Jersey,” [Chris] Christie told the Today show on Tuesday. That’s exactly the problem. The fact that a governor, almost by definition, focuses first and foremost on the short-term risk to his own state leaves him unable to consider the bigger picture.

In a speech yesterday, Obama implicitly scolded Christie and other governors who have opted for extraordinary measures such as mandatory quarantines for reacting to the epidemic “based on our fear”. Gregg Gonsalves harshly criticizes these governors, whom he says “have dealt a serious blow to the credibility of the CDC and the NIH as well”:

By instituting evidence-free policies, these politicians are effectively telling the American people, “You can’t trust the folks in Atlanta or Bethesda to take care of you, and you can’t believe their version of the facts; we know better.” It is a message that is not easily forgotten. The governors’ words and actions play into a general distrust of government and a sort of scientific denialism, where each person gets to decide what the facts are. It creates confusion about which institutions Americans should listen to, and whose advice they should follow, when it comes to public health. In ignoring the expertise and mandates of the CDC and the NIH, the governors are claiming, wrongly, that the public should look closer to home for correct guidance. The risks of this situation cannot be overstated.

In an editorial in the New England Journal of Medicine, seven doctors and public health experts underscore that mandatory quarantines are unnecessary given what we know about how Ebola is transmitted, and may in fact do more harm than good:

A cynic would say that all these “facts” [about the science of Ebola transmission] are derived from observation and that it pays to be 100% safe and to isolate anyone with a remote chance of carrying the virus. What harm can that approach do besides inconveniencing a few health care workers?

We strongly disagree. Hundreds of years of experience show that to stop an epidemic of this type requires controlling it at its source. Médecins sans Frontières, the World Health Organization, the U.S. Agency for International Development (USAID), and many other organizations say we need tens of thousands of additional volunteers to control the epidemic. We are far short of that goal, so the need for workers on the ground is great. These responsible, skilled health care workers who are risking their lives to help others are also helping by stemming the epidemic at its source. If we add barriers making it harder for volunteers to return to their community, we are hurting ourselves.

Would a 21-day, at-home quarantine with state reimbursement for lost work really inhibit health workers from volunteering in West Africa? These are people who are already intending to travel across the ocean to the most virulent hot zone on the planet – but a three-week paid vacation at home is a deal-breaker? If the threat of quarantine is enough to scare health workers away from volunteering, Amy Davidson argues, West Africa is screwed:

[Kaci] Hickox spent the night before she headed home to America watching a young girl die; that is hard enough. If the prospect of three weeks in a tent in a Jersey parking lot or, God forbid, reading the works of Andrew Cuomo discourages them, the argument goes, then the disease will spread out of control in Liberia, Sierra Leone, and Guinea, more people will flee those countries, and the United States will face a far greater risk than that posed by a doctor going to a bowling alley in Williamsburg. This is practical, but it raises another question: why, exactly, is the burden being put on already overwhelmed volunteers in the first place? Can’t we do more, and more directly? What does it say about the help available to West Africa if a little bullying by Chris Christie could make it all fall apart?

Clive Crook sensibly maintains that science alone can’t answer the policy question of how best to respond to the outbreak:

You don’t have to be a cynic, a slanted term, to argue for “better safe than sorry.” The calculus isn’t simple, either. The crucial thing, though, is that the doctors’ sensible conclusion doesn’t rest solely on the science. It requires a delicate judgment about many different risks and costs — the risk of extra U.S. cases in the short run, the risk of discouraging health workers from traveling to West Africa so that the disease keeps spreading there, the cost in civil liberty of restricting people’s movements, and so on. I agree with the doctors about where the balance lies, but the issue isn’t easy and, in any event, it isn’t just about the science of Ebola.

Quarantanamo, New Jersey, Ctd

Chris Christie went on TV this morning to defend his mandatory quarantine policy for health workers returning from Ebola-afflicted countries:

“I don’t think it’s draconian,” Christie, appearing on the Today show, said of New Jersey’s mandatory 21-day quarantine on health care workers returning from Liberia, Sierra Leone, or Guinea. “The members of the American public believe it is common sense, and we are not moving an inch. Our policy hasn’t changed and our policy will not change.” … The governor also said the CDC has been too slow to change its policies, and is now “incrementally taking steps to the policy we put in effect in New Jersey.” The CDC announced on Monday new guidelines for people traveling from West Africa, but still recommends voluntary at-home isolation rather than state-mandated quarantines.

Ben Wallace-Wells thinks “that Christie, and also [New York Governor] Cuomo, simply misread the nature of the public alarm”:

Despite the tone on cable news, and despite the wildly over-publicized decisions of a few parents in a few school districts to keep their kids home, there hasn’t been a public panic over Ebola. People are still traveling on airplanes. They are not flooding the hospitals with anxieties that minor symptoms might portend Ebola. Everyone whose job it is to predict public opinion seems to have been bracing for a panic. But it hasn’t come.

A dumb and snotty cottage industry has developed in making fun of those who are freaking out. (As I write, the most-viewed story on The New Yorker‘s website is a “humor” column by Andy Borowitz titled, “Study: Fear of Ebola Highest Among People Who Did Not Pay Attention During Math and Science Classes.”) But really there hasn’t been much excess fear at all.

Earlier Dish on that media coverage here. In Alex Altman’s view, Christie tried to score some political points from the crisis, but his plan backfired:

For Christie, the panic wrought by the lethal virus may have seemed a prime opportunity to run his favorite play: the one where the tough leader takes a common-sense stand in the face of federal dithering. This is the move that drew bipartisan plaudits after Hurricane Sandy ravaged the Jersey shore in 2012, and one Christie may hope will propel a possible presidential candidacy in 2016. The play has worked swimmingly when run against teachers’ unions, or bungling bureaucrats, or “idiots” loitering on a stretch of beach in the face of an oncoming storm. It doesn’t wear as well when the target is a nurse who risked her life to fight a deadly disease.

The Bloomberg View editors chastise the governors:

Clearly, their decision was unnecessary and premature. Yet it also displays a worrisome disconnect in national public-health networks. Some amount of public panic is to be expected, and must be addressed. State health officials, however, should know better — both about how Ebola spreads and the dangers of mandatory quarantines. … During the SARS epidemic of 2003, public health officials learned that voluntary quarantines — simply requesting that people who might have infectious illness limit their social interactions for a period of time — are as effective as forced quarantines in helping stem an outbreak.

But Noah Rothman defends Christie from the flak he’s taking from both left and right:

Chris Christie did not deserve the left’s self-satisfied recriminations when he instituted stricter measures aimed at curtailing the spread of Ebola in America, programs which enjoy broad support, and he does not merit the scorn heaped upon him by the right for refusing to indefinitely intern a person who likely does not carry the disease. The right is deeply mistrustful of Chris Christie and, on some level, he has earned their suspicion. In this case, it is clear that apprehension among the right toward Christie is verging on compulsive and insidious. Liberals did not enjoy a victory when [Kaci] Hickox was transferred out of containment, but, by insisting Christie somehow endorsed the White House’s position, the right is busily handing them one.

Has The CDC Been Too Blasé?

Yesterday, the Centers for Disease Control and Prevention issued new guidelines for people at risk of coming down with Ebola, meaning primarily health workers returning from West Africa:

On Monday, the CDC broke down people in the orbit of Ebola into four categories. Those at highest risk are anyone who’s had direct contact with an Ebola patient’s body fluids, including health care workers who suffer a needle-stick injury during a patient’s care. For those people who are at highest risk and asymptomatic, the CDC recommended restrictions on commercial travel or attendance at public gatherings. The guidelines were not specific about where a person should stay, but officials said they meant home or hospital isolation. For those with some risk, like who lived in a household with an Ebola patient but didn’t have direct contact, travel restriction can be decided on a case-by-case basis, government officials said.

But states are not bound by these guidelines and are free to implement their own protocols, as several more states have done following New York and New Jersey’s lead:

Virginia Gov. Terry McAuliffe (D) and Maryland Gov. Martin O’Malley (D) held separate news conferences Monday announcing their plans for Ebola containment. Travelers from Guinea, Liberia and Sierra Leone will be assessed by health workers and asked to agree to a 21-day monitoring protocol. Higher-risk travelers will be visited at home by health workers and asked to stay there. Individuals refusing to sign the protocol agreement or not following the rules could be involuntarily quarantined, officials said.

Georgia Gov. Nathan Deal (R) on Monday announced a more aggressive Ebola-containment policy. Travelers from West Africa who don’t show symptoms, but who are considered high risk because of “known direct exposure” to Ebola patients, will be subject to quarantine at a designated facility, Deal’s office said.

With military personnel helping fight the epidemic in Africa, the Pentagon is also taking a more cautious tack than the CDC:

Army spokesman Col. Steve Warren did not call the move a quarantine in a statement issued on Monday. Rather, he said that “about a dozen” troops were being monitored. “Out of an abundance of caution, the Army did direct a small number of military personnel (about a dozen) that recently returned to Italy to be monitored in a separate location at their home station (Vicenza),” Warren stated. “There has been no decision to implement this force wide and any such decision would be made by the secretary of Defense. None of these individuals have shown any symptoms of exposure.”

According to reports, the soldiers are being monitored away from their families for 21 days. The Army refuses to call the isolation a quarantine, although separating people for medical reasons meets the Centers for Disease Control and Prevention’s definition of quarantine.

Allahpundit ridicules the CDC’s recommendations, which in his opinion are “one notch more casual than [they] should be”:

To this day, if I’m not mistaken, Kent Brantly and Nancy Writebol don’t know how they contracted the disease in Africa; Doctors Without Borders, which naturally follows strict protocols in treating patients, has nonetheless seen 16 staffers come down with it, nine of whom died. Presumably Spencer had no reason to think he’d contracted it or he wouldn’t have gone bowling. If even trained professionals are getting caught by surprise in their exposure, why would the CDC err on the side of less quarantine once they’re back home? The public’s confidence in the agency is going to get much, much worse, needless to say, if we end up with another transmission from the “low” or “some risk” category.

The irony of all this, as Tim Cavanaugh notes, is that it’s the doctors at the centers of it who are making the public more, not less, anxious (not “panicked,” as is often wrongly said). If Spencer and Snyderman had diligently quarantined themselves, the public would have greater faith that voluntary quarantines are an acceptable alternative to the sort of state-imposed measure that Christie’s getting hammered for today.

And Jazz Shaw insists that protocols that rely on voluntary quarantines and self-reporting simply aren’t good enough:

People facing a potentially dire situation will frequently be in denial. We see that all the time with folks who avoid going to the doctor only to find out later that all of those warning signs were, indeed, cancer. But if you can’t bring yourself to admit it in your own mind, you likely won’t be checking off those boxes on a form either. Further, you might be thinking that it can’t possibly be Ebola, so why would I go through all the hassle of reporting this? Where would they get that idea? Maybe from hearing an endless stream of government spokesmodels being paraded across your television screen telling you that it’s almost impossible to catch in the first place. And if you’ve had that drilled into your head often enough, who wants to go get locked up in their house for three weeks for what is almost certainly just a case of the flu?

Follow all of our Ebola coverage here, compiled primarily by Jonah Shepp, the irrepressible young Dish editor.

So When Should We Start To Panic?

Poniewozik characterizes cable news coverage of the Ebola outbreak as a struggle between the “story” and the facts:

Thursday night, the facts were: Someone in New York City had Ebola. Dr. Craig Spencer, who had been volunteering with Doctors Without Borders treating patients in Guinea, had come back to Manhattan. He’d followed the accepted guidelines for self-monitoring, checking his temperature twice daily, and watching, per the medical organization’s guidelines, for “relevant symptoms including fever.” When he detected a fever that morning–before which, he would not have been infectious–he went to the hospital.

But then there’s the story! The story was that the day before Spencer went to the hospital, he went bowling! He rode in an Uber vehicle! He went jogging and ate at a restaurant and walked in a park. He rode the subway–the crowded subway! None of this, according to medical science on Ebola, presented a danger from a nonsymptomatic person. But it felt wrong in people’s guts. And that makes a better story.

But using data on the focus and tone of media coverage from the GDELT project, Kalev Leetaru calculates that the MSM has actually handled this story more responsibly than we think:

Only when the disease literally landed on American soil did it suddenly become news.  Yet, Ebola Viruscoverage of the disease has remarkably become less negative over the past seven months, transitioning from graphic descriptions of the disease’s symptoms to the “miraculous” interventions of modern medicine and stories of survival. As William Randolph Hearst famously noted, conflict sells newspapers; yet in the case of Ebola it seems that coverage has trended towards emphasizing recovery than end-of-the-world panic. Even the level of anxiety, while trending higher in news reports, has not spiraled out of control.

A reader feels that much of the media commentary has actually been too blasé:

More people have died so far this year from Ebola than the entire history of the Ebola (first known human case is 1976). Prior to last year, 1,590 people died from Ebola. So over the last 40 years and 24 outbreaks, we have had 1,590 deaths. We are already past 5,000 this year.

Ebola is extremely infectious (it takes a very small amount of the virus to infect you, as little as a single virus) but only moderately contagious. Because only poor people in Africa have previously died of Ebola, and in very small numbers when compared to other illnesses, Ebola hasn’t been studied at the level that rich person illnesses have.  This is why I’m less than fully convinced that researchers have enough information to be 99% sure about how contagious Ebola is at any stage of illness. There just are not that many data points, and those they have (with regards to humans anyway) are under less than ideal conditions.

So, is there some middle ground between full quarantine and partying like it’s 1999?  Maybe not locked in their house, but also not allowed to go to restaurants or bowling alleys or mass gatherings of people or use mass transportation systems?

For more on the devastating nature of the disease, and how it could spiral out of control, check out Richard Preston’s disquieting piece in The New Yorker. On the “extremely infectious” nature of Ebola:

Experiments suggest that if one particle of Ebola enters a person’s bloodstream it can cause a fatal infection. This may explain why many of the medical workers who came down with Ebola couldn’t remember making any mistakes that might have exposed them. One common route of entry is thought to be the wet membrane on the inner surface of the eyelid, which a person might touch with a contaminated fingertip. … In a fatal case, a droplet of blood the size of the “o” in this text could easily contain a hundred million particles of Ebola virus.

On its ability to travel through the air:

Khan worked long hours in the Ebola wards, trying to reassure patients. Then one of the nurses got sick with Ebola and died. She hadn’t even been working in the Ebola ward. The virus particles were invisible, and there were astronomical numbers of them in the wards; they were all over the floor and all over the patients.

There are two distinct ways a virus can travel in the air. In what’s known as droplet infection, the virus can travel inside droplets of fluid released into the air when, for example, a person coughs. The droplets travel only a few feet and soon fall to the ground. The other way a virus can go into the air is through what is called airborne transmission. In this mode, the virus is carried aloft in tiny droplets that dry out, leaving dust motes, which can float long distances, can remain infective for hours or days, and can be inhaled into the lungs. Particles of measles virus can do this, and have been observed to travel half the length of an enclosed football stadium.

Ebola may well be able to infect people through droplets, but there’s no evidence that it infects people by drying out or getting into the lungs on dust particles. In 1989, a virus known today as Reston, which is a filovirus related to Ebola, erupted in a building full of monkeys in Reston, Virginia, and travelled from cage to cage. One possible way, never proved, is that the virus particles hitched rides in mist driven into the air by high-pressure spray hoses used to clean the cages, and then circulated in the building’s air system. A rule of thumb among Ebola experts is that, if you are not wearing biohazard gear, you should stand at least six feet away from an Ebola patient, as a precaution against flying droplets.

And finally, on the volatility of the virus:

A sample of the Ebola now raging in West Africa has, by recent count, 18,959 letters of code in its genome; this is a small genome, by the measure of living things. Viruses like Ebola, which use RNA for their genetic code, are prone to making errors in the code as they multiply; these are called mutations. Right now, the virus’s code is changing. As Ebola enters a deepening relationship with the human species, the question of how it is mutating has significance for every person on earth.

Read the whole riveting piece here. (Preston wrote the 1994 bestselling book, The Hot Zone: The Terrifying True Story of the Origins of the Ebola Virus.) One more reader:

If you want to read the scary stuff about where Ebola could be headed, here it is (and the primary source for the article is here). If we can’t find the strength to help Africa contain this, it could get much, much worse for the rest of the world. We shouldn’t be worried about isolated cases showing up in NYC or Chicago or Dallas. We should be worried about Mumbai and Karachi and similar places with similar slum populations.

Follow all of our Ebola coverage here.

(Photo via Getty)

Quarantanamo, New Jersey


Late Friday, governors Cuomo and Christie announced a mandatory 21-day quarantines for anyone arriving in the US through the Newark and JFK airports if they had direct contact with Ebola patients in Guinea, Liberia, or Sierra Leone. Cuomo blinked yesterday and relaxed the new rule for his state after strong objections from public health groups and the White House:

Originally, Cuomo and … Christie announced a joint initiative to require a governmental quarantine for 21 days for all health care workers flying into their states. Illinois soon followed suit. But under the new guidelines, Cuomo said returning health care workers can instead quarantine themselves in their homes for 21 days, and will receive at least two unannounced house calls from local health officials. The state will provide services like food and medicine if the health-care worker needs it. Health care workers will also monitor their symptoms, as has been the standard for the vast majority of people returning from work in the region. “If their organization does not pay for the three weeks, we will,” Cuomo said during a press conference Sunday night.

Christie has also walked back his order somewhat. Nurse Kaci Hickox, the first person subjected to the New Jersey quarantine order, is set to be released today and allowed to finish her quarantine at her home in Maine after threatening to take legal action against the state over her treatment:

The nurse’s treatment has drawn withering criticism from both public health officials and the nurse herself. At University Hospital in Newark, Ms. Hickox has been kept in an isolation tent with a portable toilet, but no shower or television. … Ms. Hickox called her treatment inhumane and castigated Governor Christie for saying she was “obviously ill” when she displayed no symptoms of Ebola.

Kent Sepkowitz calls these quarantine orders an overreaction that won’t do anything for public health:

Indeed, there is a consequence to Christie and Cuomo’s decision that endangers the safety of the rank and file of New Jersey and New York far more than it protects it. Searching for a bump in some internal poll or perhaps because it feels good to make a damn decision once in a while, the governors know but choose to ignore the obvious big fact: There is a larger crisis occurring in redoubts well beyond Trenton and Albany. Their move, though perhaps it plays well now, will have a desiccating impact on volunteerism; this in turn will make the African epidemic worse, which will make it more likely cases will appear in the United States, which will increase the risk of Ebola for John Q. Public as he wanders through Trenton and Albany, Brooklyn and Newark.

Cohn piles on:

It’s also an open question whether the quarantine reduces anxiety or intensifies it. That’s particularly true in this case, because Cuomo’s statements on Friday, at least as relayed by the press, left the impression that a non-symptomatic Ebola patient could spread the disease on the subwaythe very notion that public health officials had spent the previous 24 hours explaining wasn’t true. That’s one reason that officials from the Obama Administration, the CDC and the New York City Department of Public Health seemed not at all happy about Friday’s announcement. The other is that, based on what I’m reading in outlets like the Times and hearing from insiders, they weren’t so much consulted about the decision as informed of it at the last minute, as a fait accompli.

So does Josh Voorhees:

If Cuomo, a Democrat, and Christie, a Republican, do believe they’re acting in the public’s best interest, then they haven’t done their research. Public health experts have made it clear that quarantining asymptomatic individuals will do little if any good. More troubling is the risk of a cascade of unintended consequences that could make it more difficult to contain the virus in West Africa, where it has already claimed more than 5,000 lives and will likely claim thousands more.

At best, the bipartisan pair is giving in to the fears of a misinformed public. At worst, Christie and Cuomo—whose respective presidential ambitions are no secret—are capitalizing on those fears to score cheap political points by appearing to be guardians of their constituents’ safety. The chance to bolster their respective profiles appears too good for them to pass up, even if such gains are paid for by risking West African lives.

The orders might even be unconstitutional:

Lawrence Gostin, a law professor at Georgetown University who has been in touch with Hickox about her legal options, said he thought the quarantine order was illegal and unconstitutional. He noted that since you can’t catch Ebola from someone unless they are both infected and showing symptoms, Hickox poses no danger to the public. “The courts are very suspicious when you deny a whole class of people their liberty,” he said. “She’s being detained because she’s a member of a large class of people who happened to have been in the region.”

But Jazz Shaw is disappointed in Cuomo for backing off:

Having them stay at home is doable, but only if we have confidence that they actually will stay at home, rather than going out bowling, playing basketball and riding the subway. That will require monitoring, but the monitors need to look like bellhops more than prison bulls. It’s a tricky situation to be sure, but it could be handled. Sadly, it seems that Cuomo has left Christie hanging in the wind and will – as predicted – bend in the direction of Washington.

Why Do Americans Go Out Sick? Ctd

A reader shakes his head:

The post this morning in which Julia Ioffe blames American individualism for the tendency of Americans to go to work or school sick is missing the fundamental cause. According to a report by the Center for Economic Policy and Research, the United States is the only advanced economy that doesn’t guarantee paid vacation time and is one of only a few rich countries that doesn’t require employers to offer at least some paid holidays. A full quarter of the US workforce receives no paid vacation or holiday time. It shouldn’t be surprising to find that when faced with the prospect of not getting paid or giving up scarce vacation days, American workers choose to show up sick.

Another notes that even businesses with sick-leave policies discourage workers from calling in with the flu:

Many companies pay employees not to use sick time, encourage them to ration it for when things get “really bad,” or actively prohibit its use. For example, they have policies that don’t allow employees to use sick time during their “probationary period” of six months to a year. This makes it seem normal to go about business as usual even when you feel like something the cat dragged in off a pile of hazmat suits.

Another adds, “Even if you get sick leave and using it doesn’t cut your vacation, you’d better not use more than half of it in any given year unless you’re actually in the hospital”:

Because if you do, management will assume that either a) you’re calling in sick when you are not in order to get a paid day off, or b) you’re a slacker who is unwilling to put out a little extra effort in order to get the job done. Either of which is grounds for termination, or at the minimum a bad performance review, which will get you to the head of the queue next time layoffs come around. The job is, obviously, more important than something trivial such as the health of the staff.

Note also that, if your job allows telecommuting, you will be expected to be working from home, even if you stay home because you are sick.

Another illustrates how sick children can be a major factor:

I’ve lived in rural South Texas for 35 years, and my two children attended a public elementary school in a very small town. In order to encourage economically disadvantaged children with limited English skills to get all the way through high school, our area rewards children at the elementary level for “100 percent attendance.” This isn’t strictly a rural phenomenon; I believe our nearest metropolitan area, a city of several hundred thousand people, has a similar practice.

As a result, the number of children who would show up at my kids’ school with fevers and running noses was appalling. Their parents would drop them off with a cheery and proud assurance that this was at their child’s insistence: “They want to win that attendance award!” So civic responsibility was removed from the list of things learned at school early on. Lately, I believe, a regular school nurse has started removing children who are running a fever from class.

And consider the problem of families with working parents. What does one do with a sick child who should be at home in bed when no one is home to care for them and paid child care is out of the question? Indeed, many Americans, with or without children, go out sick because they have no other alternative if they want to pay their bills. These are not the people Julia Ioffe is describing – people who are, indeed, insufferably self-centered and who do more damage showing up for work sick than they realize.

Protestant work ethic? Nah. Just being a self-centered asshole? Could be. Just trying to get by? More likely.