In the wee hours of a rainy Monday, more than a dozen buses sat on the tarmac at Tokyo’s Haneda Airport. Inside, 328 weary Americans wearing surgical masks and gloves waited anxiously to fly home after weeks in quarantine aboard the Diamond Princess, the luxury liner where the novel coronavirus had exploded into a ship-wide epidemic.
But as the buses idled, U.S. officials wrestled with troubling news. New test results showed that 14 passengers were infected with the virus. The U.S. State Department had promised that no one with the infection would be allowed to board the planes.
A decision had to be made. Let them all fly? Or leave them behind in Japanese hospitals?
In Washington, where it was still Sunday afternoon, a fierce debate broke out: The State Department and a top Trump administration health official wanted to forge ahead. The infected passengers had no symptoms and could be segregated on the plane in a plastic-lined enclosure. But officials at the Centers for Disease Control and Prevention disagreed, contending they could still spread the virus. The CDC believed the 14 should not be flown back with uninfected passengers.
“It was like the worst nightmare,” said a senior U.S. official involved in the decision, speaking on the condition of anonymity to describe private conversations. “Quite frankly, the alternative could have been pulling grandma out in the pouring rain, and that would have been bad, too.”
The State Department won the argument. But unhappy CDC officials demanded to be left out of the news release that explained that infected people were being flown back to the United States – a move that would nearly double the number of known coronavirus cases in this country.
The tarmac decision was a pivotal moment for U.S. officials improvising their response to a crisis with few precedents and extraordinarily high stakes. Efforts to prevent the new pathogen from spreading have revealed the limits of the world’s readiness for an unprecedented public health emergency. In the worst-case scenario, covid-19, a flulike respiratory infection, could become a full-blown global pandemic.
Navigating the crisis has required delicate medical and political judgments. The decision to evacuate the Americans from the Diamond Princess came only after infections on the cruise ship spiked and passengers revealed their grim living conditions.
One lesson from that debacle is that cruise ships are like Petri dishes. Thousands live in close quarters on a vessel never designed as a medical quarantine facility. The crew continued to deliver food, and health workers moved throughout the ship. More than 600 of the 3,700 passengers and crew members have now tested positive for the virus and two older Japanese passengers have died.
With Japanese authorities quarantining the passengers for weeks off the coast, the ship quickly developed the second-largest number of coronavirus cases on the planet outside of China – more than in Japan, Singapore, Thailand, the United States or all of Europe. Avoiding “another China” has been the goal of the World Health Organization for weeks, and then it happened anyway, in Yokohama harbor.
The treatment of the Diamond Princess passengers stands in stark contrast to what happened to those on another cruise ship, the Westerdam, who were greeted by the Cambodian prime minister with handshakes and flowers, and who later traveled widely. Only later did news come that one of the Westerdam passengers had tested positive for the virus.
That situation spurred fears that Westerdam passengers would spread the virus around the world. But no additional passengers have tested positive, and so far, no evidence has emerged they have widely seeded the virus.
The coronavirus (officially, SARS-CoV-2) is extremely contagious. Experts estimate that without protective measures, every infected person will spread it to an average of slightly more than two additional people. The disease, covid-19, has been fatal in roughly two out of 100 confirmed cases.
Travelers have already spread it to more than two dozen countries, where it has infected more than 75,000 people and killed more than 2,000.
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The Diamond Princess left Yokohama for a 15-day cruise on Jan. 20. One man from Hong Kong left the ship when it docked there five days later, and checked into a hospital. On Feb. 1, officials confirmed he was infected with the coronavirus.
Spencer Fehrenbacher, 29, an American studying for his master’s degree in China, signed up for the cruise with friends as a break between semesters. Just a couple of days in, they became alarmed about reports of the virus spreading in China.
In Vietnam, he came down with a fever. It lasted only 24 hours, but he feared he might have the virus. He decided not to get off at the next two stops, in Taipei and Okinawa, because he was afraid he’d wind up quarantined.
The ship sped back to Yokohama and docked on Feb. 3. Japanese authorities told passengers they could not leave.
The next day, they mingled onboard. Many ate a buffet dinner, but the casino was closed and the evening show canceled. That night, the captain ordered passengers to return to their cabins and stay there until quarantine officers came to see them.
Over the next several days, test results trickled in: Dozens had become infected. Fehrenbacher kept fearing the worst.
“I was sitting there all day waiting for what I call the knock of doom on the door,” he said.
Fehrenbacher stayed in his room – every day, all day. He had a balcony and that was good enough. He started using the word “optimistic” when he spoke to friends and family, because “positive” carried a bad connotation.
He recorded a video and sent it to his brother to share with his family in case he was hospitalized and unable to communicate, or even died. “Mom, Dad, I love you, I miss you. I’m sure everything will be OK,” he recalled saying.
Five days after the ship reached port, the CDC wrote a letter to the American passengers saying that “remaining in your room is the safest option to minimize your risk of infection,” and adding, “We acknowledge that this situation is difficult.”
For nearly two weeks, the only way off the Diamond Princess was through illness, and a ride by ambulance to further isolation in a hospital.
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For some, the difficult situation became dire. By the score, people tested positive. The crew members, meanwhile, were forced to stay at their jobs.
Some 200 passengers were over the age of 80, at much higher risk of dying from the virus.
“Obviously, the situation on the ground changed, and clearly there’s been more transmission than expected on the ship,” said Michael Ryan, a WHO executive director for health emergencies. “It’s very easy in retrospect to make judgments on public health decisions made at a certain point.”
On Feb. 12, U.S. officials briefed members of Congress in a closed-door hearing. Rep. Phil Roe, R-Tenn., a doctor, had also heard from a friend and fellow doctor, Arnold Hopland, of Elizabethton, Tennessee, who was on the ship with his wife, Jeanie. Hopland told Roe about the deteriorating conditions.
“That tipped the balance,” said the senior administration official.
By Friday afternoon in Washington, there was agreement among all the agencies in the U.S. coronavirus task force to evacuate the Americans.
The State Department, through the U.S. Embassy in Tokyo, posted an urgent notice to U.S. citizens: Americans who wanted to leave needed to let the embassy know by 10 a.m. Saturday local time in Tokyo.
In all, 328 Americans disembarked from the ship in the early hours of Monday, Tokyo time. They boarded buses – and then were forced to wait, still in the port, for more than two hours, according to two passengers. They couldn’t see out of the buses – the windows were covered.
Some began crying because they needed to use the bathroom, said Vana Mendizabal, 69, of Crystal River, Florida. The retired nurse had taken the cruise with her husband, Mario, 75, a physician.
“We just couldn’t understand why we were sitting there, loaded, and not going anywhere,” she said. “And we couldn’t get any answers.”
Eventually the buses arrived at the airport, and once again, everyone waited while top officials in Washington argued about the test results, according to a senior administration official.
“Nobody anticipated getting these results,” said another U.S. official involved in the evacuation.
During one call, the CDC’s principal deputy director, Anne Schuchat, argued against taking the infected Americans on the plane, according to two participants. She noted the U.S. government had already told passengers they would not be evacuated with anyone who was infected or showed symptoms. She was also concerned about infection control.
Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, who was also on the calls, recalled saying her points were valid and should be considered.
But Robert Kadlec, assistant secretary for preparedness and response for the Department of Health and Human Services and a member of the coronavirus task force, pushed back: Officials had already prepared the plane to handle passengers who might develop symptoms on the long flight, he argued. The two Boeing 747s had 18 seats cordoned off with 10-foot-high plastic on all four sides. Infectious disease doctors would also be onboard.
“We felt like we had very experienced hands in evaluating and caring for these patients,” Kadlec said at a news briefing Monday.
The State Department made the call. The 14 people were already in the evacuation pipeline and protocol dictated they be brought home, said William Walters, director of operational medicine for the State Department.
As the State Department drafted its news release, CDC’s top officials insisted that any mention of the agency be removed.
“CDC did weigh in on this and explicitly recommended against it,” Schuchat wrote on behalf of the officials, according to an HHS official who saw the email and shared the language. “We should not be mentioned as having been consulted as it begs the question of what was our advice.”
She wrote that the infected passengers could pose “an increased risk to the other passengers.”
Schuchat declined to comment.
About an hour before the planes landed in California and Texas, the State Department revealed that the 14 evacuees had tested positive, and did not mention the CDC.
Mendizabal, the retired nurse, said she learned about the infections only when she landed at Travis Air Force Base in California and talked to one of her five children, who had seen a news report.
“We were upset that people were knowingly put on the plane who were positive,” she said Wednesday in an interview from the military base. She said she and her husband had already completed 12 days of quarantine on the ship and both were healthy.
“I think those people should not have been allowed on the plane,” Mendizabal said. “They should have been transferred to medical facilities in Japan. We feel we were re-exposed. We were very upset about that.”
Scientists are still trying to understand the virus. Some of its features, such as how long it can live on surfaces, are unknown. But experts say it is mainly spread by respiratory droplets produced by coughs and sneezes from an infected person. That person must be in close contact, usually defined as six feet.
“We still don’t have a good understanding of the risk posed by people who are infected but without symptoms,” said Jeffrey Duchin, an infectious disease specialist at the University of Washington.
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Thousands of miles away, a different scene was playing out in Cambodia.
The Westerdam, a luxurious Holland America Line ship with 2,257 passengers and crew, spent days searching for a port amid fears that it might have infected passengers aboard – even though there was no evidence of it. The ship was turned away from five ports, including Guam.
But the Westerdam finally was embraced Feb. 13 by Cambodia, a nation with close ties to China and whose authoritarian prime minister, Hun Sen, has used the coronavirus crisis to advance his country’s political interests.
Having lost a preferential trade arrangement with the European Union over human rights abuses, Hun Sen used the Westerdam as a vehicle to alter headlines and potentially improve relations with the West.
When the ship sailed into Sihanoukville last Thursday, he rolled out the red carpet. Without any protective gear – not even a mask or gloves – he greeted each of the passengers as they disembarked, shaking their hands as he passed out bouquets of flowers.
U.S. Ambassador W. Patrick Murphy also went to the dock with his family to welcome passengers. Murphy wore no face mask or gloves, and maintained little distance between himself and jubilant, relieved passengers.
They filed off and dispersed to hotels, hundreds to the luxury Sokha in Phnom Penh, a little more than 100 miles away. There, some went out to dinner, assured by Cambodia and cruise ship officials that among the 20 people who were tested for the virus, none was positive. Others took a bus tour.
More than 700 headed for the airport and flights to homes around the world.
Then came startling news. On Saturday night, an 83-year-old American woman, as yet unidentified, tested positive for coronavirus in Malaysia. Her husband, who also has symptoms of the respiratory illness, tested negative.
Suddenly, as if flash frozen, the exodus from the Westerdam halted. Hundreds of passengers and crew were ordered to remain onboard. Others retreated to the Sokha hotel, where they were asked to stay in their rooms – a request some ignored, said Christina Kerby, 41, of Alameda, California, who had taken the cruise with her mother.
Kerby had spent Saturday relaxing at the hotel. She went for a swim, then out to dinner, publishing photos of her meal on Twitter for followers who had been tracking her ordeal over the previous two weeks.
“It was my afternoon to relax before a long trip home,” she said.
Kerby has received blowback on Twitter for going out in Phnom Penh. Back home in Alameda, her children’s preschool asked whether she might endanger other kids when she returns. The stigma of the virus is a new feeling, she said.
On Sunday, she awoke to find a note slipped under her door informing her of the passenger’s positive test and asking that she stay in her room.
“That, for me, was the moment I lost it,” said Kerby who had been relentlessly optimistic during her cruise ship confinement. “As Americans, we’re very used to having agency over our own bodies and being able to come and go as we pleased.”
Now, health experts say, there is little to do but wait and see whether the Westerdam passengers spread the virus around the world. Some are skeptical they will see that, suggesting the single positive test result may have been erroneous.
“You would assume if one person got infected on any cruise, you would have a mini-outbreak,” said one U.S. official involved in the response. “Maybe she wasn’t positive.”
Based on what is known so far, Cambodia’s approach is preferable to quarantining people aboard a ship where the virus is spreading, said Saskia Popescu, senior infection prevention epidemiologist for HonorHealth, a hospital system in Phoenix.
But that requires educating passengers about reporting symptoms and self-isolating if necessary, and having public health authorities in home countries closely monitor those who have returned. It includes quickly tracing the contacts of anyone who develops the infection.
“I think we can say if you’re going to quarantine people, doing it on a cruise ship is not the best place,” Popescu said.
In an interview with The Washington Post, Phay Siphan, the Cambodian government spokesman, expressed no regrets on the handling of the Westerdam and its passengers.
“The ship was abandoned by the Earth,” he said. “We understood their predicament, and we knew we had to help them.”
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Christina Kerby initially struggled to find a flight home from Cambodia.
“It literally is minute by minute over here,” she said Wednesday. “One minute, they think they have an agreement with a country to let us through and the next, people are being held at the airport.” She arrived in San Francisco Thursday.
Fehrenbacher, the graduate student, described his room at Travis Air Force Base as surprisingly spacious. He was told that for 48 hours, he could not leave the room. To receive a meal from uniformed personnel, he must first put on a mask.
“I’m just trying to stay hydrated and optimistic about what the next 12 days are going to look like,” he said.
In Japan, meanwhile, the Diamond Princess is finally being vacated. On Wednesday, Japan released 443 people from the ship, saying they had completed their 14-day quarantines.
Scores of its passengers, about 40 of them Americans, remain hospitalized with the infection.
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Mahtani reported from Hong Kong. Simon Denyer in Tokyo, Meta Kong in Phnom Penh and William Wan and Alex Horton in Washington contributed to this report.