Uncertainty and agency in COVID-19 hotel quarantine in Australia.

Mandatory 14-day hotel COVID-19 quarantine was introduced for international arrivals into Australia in late March 2020, with no precedent and little time to prepare. This public health initiative was a key factor in Australia's relatively low COVID-19 burden in the first 18 months of the pandemic. We conducted an empirical bioethics study exploring the experience of people who had quarantined in hotels in Australia. We used in depth interviews to develop an understanding of context and normative analysis to consider whether the way the program is conducted is ethically justifiable. 58 people participated; they had been in hotel quarantine in different parts of Australia in the period March 2020-January 2021. Participants faced considerable uncertainty while in quarantine and many experienced this as burdensome. Some uncertainty resulted from not being given information about key aspects of quarantine, some from rules that changed frequently or were otherwise inconsistent, some from being physically isolated. Lack of information and uncertainty contributed to diminished agency. Communication efforts made by individual hotels was well received. Earlier ethics literature about quarantine does not take into account the context our participants described, where the hotel and supervision arrangements were central to the experience. We argue that more suitable arrangements must be made if quarantine is to be an ongoing proposition.

Introduction

Australia has had a low burden of COVID-19 morbidity and mortality relative to other countries. From the first reports of infection in the region in the first days of 2020 until the second half of 2021 the state and territory governments pursued a strong COVID suppression strategy, keeping infection out of the country and eliminating rare outbreaks via contact tracing and public health restrictions. Central to this approach was the adoption of strict border control measures. These included travel restrictions and border closures and, from March 28, 2020, mandatory 14-day hotel quarantine (MHQ) for international arrivals. The use of hotels for quarantine was a response to the urgency of the need (there was less than 24 ​h between the policy announcement and it taking effect) (Office of the Prime Minister of Australia, 2020), lack of existing suitable state- and territory-run facilities, as well as the economic boost to a sector in which demand had disappeared overnight.

As of late 2021, SARS-CoV-2 was circulating in the community and border restrictions eased in Australia's most populous and most highly vaccinated states but remained in place in other states and territories. Domestic travellers crossing state and territory borders have also been required to quarantine in hotels when there have been outbreaks in the jurisdictions of their travel origin. Hotel quarantine for international arrivals has been administered and funded by state and territory governments under federal international border rules, but with no federal management oversight. A fixed charge to travellers for quarantine expenses was introduced in July 2020. This fee is around 3000 AUD per person, but varies according to jurisdiction and the number of people traveling together. (e.g.(New South Wales Government, 2021)).

Australia was among the first countries to introduce mandatory hotel quarantine for international arrivals and, as with so much of the early response to the SARS-CoV-2 pandemic, decisions had to be made rapidly in a context of great uncertainty. Strict quarantine measures have undoubtedly been a crucial part of Australia's relative success in managing COVID-19. With the exception of sustained community transmission in Victoria in the period June–September 2020, most detected COVID-19 infections in Australia from March 2020–July 2021 were in returned overseas travellers and were limited to quarantine facilities.

Quarantine in the Australian context

Australia has long used border restrictions (or “border protection”) to produce a particular social and political national vision, from its White Australia policy (1901–1973)(Mayes, 2020) to ongoing mandatory detention of asylum seekers (Bashford, 2002). A pattern of focusing on ‘security’ through physically barring perceived threats from the island nation has fed into a ‘Fortress Australia’ narrative, one that carries with it a particular kind of exclusion-based nationalism. In this vein, quarantine and border restrictions have been used to respond to the threat of disease since Australia's colonial era. In one interpretation, Alison Bashford describes the imaging of Australia as an island state where ‘island’ stands for ‘immunity’, and national ‘healthiness’ is tied to keeping undesirable others out (Bashford, 1998). Quarantine is a bounded space that delineates (potentially) diseased from healthy, dirty from clean, risky from safe (Armstrong, 1993). It would be disingenuous to talk about Australia's supervised COVID quarantine program without at least acknowledging these historical precedents (Nethery & Ozguc, 2021). Bashford cites Elkington, who wrote in 1912 that:

Civilised countries nowadays keep themselves free of dangerous epidemic diseases by keeping them out. Quarantine has been organised, as all public services have been organised, until it is now a very fine-meshed net stretched round a country so that all disease, whose introduction might have serious consequences is caught and stopped from entering. Australia is in a fortunate position. (Bashford, 1998) (p393)

With a few word tweaks, this could have been written today as Fortress Australia continues to enjoy popular support. Australians have been regularly reminded that they are, in fact, in a fortunate position relative to the rest of the world, and that quarantine, and international and domestic border control measures have been at the heart of this. It is likely this historic comfort with separation and isolation contributed to swift border closures and strict quarantine. Until the last quarter of 2021 Australia had very low vaccine uptake relative to other OECD countries, and Australia was heavily reliant on so-called ‘non-pharmaceutical interventions’ to keep SARS-CoV-2 out of the community.

Ethics and quarantine in the literature

Many countries' public health laws allow for quarantine to be used to restrict the movement of people with an increased likelihood of exposure to an infectious disease (e.g. Ebola, plague, infectious tuberculosis). Prior to the SARS-CoV-2 pandemic, academic writing on the ethics of quarantine focussed on its use within communities to respond to acute outbreaks, rather than as a means of keeping infection out of communities (or countries) altogether. Quarantine is a restrictive public health measure to be invoked justifiably only in situations of extremely heightened risk. The policy in Australia of designating quarantine in a hotel, and charging for it, requires justification given there are other alternatives available e.g. quarantine in one's own home.

Much of the pre-SARS-CoV-2 pandemic quarantine literature is framed around human rights and prioritises the infringement of liberty as a key concern. The Siracusa Principles (United Nations, 1985) state that a government must use the least restrictive means to achieve desired outcomes in (public health) emergency quarantine situations. In the context of quarantine, Wynia practically interpreted the principles thus: “[D]on't use involuntary quarantine or surveillance devices such as bracelets if voluntary measures will work; don't restrict someone to one room if an entire house is available; don't preclude visitors if personal protective equipment is effective; and don't cut someone off from their work if they can do it from inside quarantine.” (Wynia, 2007) Upshur added three additional principles to least restrictive means: there must be a clear threat of harm, reciprocity must be upheld, and the program and process must be transparent (Upshur, 2002). To these, Gostin et al. introduced the idea of compensating people for e.g. lost wages, but argued in the context of SARS in 2003 that while quarantine is a “severe deprivation of liberty” it is justifiable (Gostin et al., 2003). Giubilini and colleagues argued that people have a moral responsibility to submit to state enforced quarantine, on the grounds that it generated a small sacrifice for some for the greater good of those around them, but that the burden must be minimised by measures of reciprocity (Giubilini et al., 2018). COVID quarantines have involved much larger populations than earlier modern epidemics, including SARS e.g. (Levenson, 2020; Sylvers & Legorano, 2020). In early 2020, Gostin wrote that such measures seemed legally and ethically inconceivable in the United States (Gostin, 2020) and that imposition of quarantine that is not risk-based would be unlikely to be legal (Gostin & Wiley, 2020). It would appear, therefore, that the ethical justifiability of quarantine changes over time and place and depends on the conditions under which it is implemented.

Crucially, none of the infectious disease emergency ethics literature on quarantine is premised on it taking place mandatorily in a hotel. The location of quarantine is usually not explicitly discussed beyond noting that it may be difficult for some people to be able to safely quarantine at home (e.g. people experiencing homelessness, people living in crowded housing) – by which we can probably assume that quarantine was envisaged to be home based in the ethics literature. Hotel quarantine was, to use that now well-worn word, ‘unprecedented’ before the COVID-19 pandemic.

This paper draws on an empirical study of reported lived experiences of mandatory hotel quarantine in Australia and provides the context for a normative analysis of the justifiability of hotel quarantine that is attentive to this context. More specifically, we report on the role of information in hotel quarantine and the relationship between not knowing and reduced agency. We interpret our findings with respect to Australia's particular relationship with quarantine and restricted borders and with the ethics literature on quarantine in mind.

Methods

Design

This is an empirical bioethics paper. Empirical bioethics is highly applied; it situates ethical analysis in a well explored and understood context. We were guided by published methodologies that emphasise the relationship between theory and practice (Carter et al., 2019; Ives et al., 2018). We use qualitative methods to develop a deep understanding of a particular experience and normative analysis to consider whether the way MHQ is conducted in Australia is morally justifiable. It is part of a larger study that looks at COVID-19 related quarantine in Australia. This paper reports on a large subset of interviews carried out for a study about MHQ in Australia in the period March 2020–January 2021.

Participants were recruited via social media (Facebook groups relating to hotel quarantine, Twitter) and word of mouth. Some shared information about the study with others who had been in quarantine. People who took part in an interview were offered a $100 gift card for their time. Prospective participants were given information about the study in advance of interviews, and this was discussed prior to oral consent. Interviews were conducted via Zoom (n ​= ​56) or telephone (n ​= ​2) by BH and JW; they lasted between 35 and 95 ​min with a median of 51 ​min. Interviewers used an agreed flexible question route, which changed slightly for each phase to add questions specific to the scenario of interest. All participants consented to having their interview recorded. Interview files were labelled with a pseudonym and transcribed by a professional third party. Potentially identifying details were removed from transcripts. In the case of one interview, the transcript was edited for anonymity in consultation with that person at their request.

Approval for the study was granted by the University of New South Wales (HC200275).

Interviews took place over 3 distinct temporal phases. Each phase was triggered by a new or changed MHQ policy. During the first phase we interviewed 30 people: 15 who had completed 14-day quarantine at home, in the weeks before hotel quarantine was mandated (in March 2020), and 15 people who had experienced mandatory hotel quarantine in its early days (March 28 – May 2020). In the second phase we interviewed 11 people who had been quarantined in two hotels in Victoria which were subsequently identified as the sources of COVID-19 infection that ‘leaked into the community’ and deemed unfit for purpose (April–June 2020). Finally, in Phase 3 we interviewed a further 32 individuals who completed mandatory hotel quarantine later in 2020, when they were required to pay for quarantine (August 2020–January 2021). This paper reports only those experiences of mandatory quarantine in hotels or the designated quarantine facility in the Northern Territory so includes interview data from 58 participants. Where quotes from participants are used, the state and date refer to the quarantine location and time.

Participants

Participants were aged 19–75. All of the participants were Australian citizens or permanent residents returning to Australia from abroad. The Phase One cohort was made up largely of two groups: people whose Australian employers had required them to return to Australia, or; people who had moved overseas in early 2020 and did not have well-established lives abroad when the pandemic hit. Phase Two was made up mostly of tourists or longer-term travellers who had been ‘stuck’ overseas for a reasonably short period. Phase Three was mixed but included people who had travelled for family reasons, and people who had lived abroad for a long time whose circumstances had forced their return. Table 1 summarises participant and quarantine details. We do not claim a representative sample of people who had experienced hotel quarantine; we consider it likely that the people who saw the Facebook recruitment advertisement had strong views about the experience because they were motivated to join a group about the topic.

Table 1

Summary of participants in mandatory hotel quarantine.

Participant summary
Gender	/58	%	Quarantine group	/59∗	%
Male	19	33	Alone	29	49
Female	39	67	With another adult	20	34
Age	/58	%	With partner and children	7	12
19–29	12	21	With children	3	5
30–39	17	29	Location	/59∗	%
40–49	10	17	New South Wales	28	47
50–59	3	5	Victoria	13	22
60–69	13	22	Western Australia	2	3
70–75	3	5	Northern Territory∗∗	6	10
∗Totals 59 because one participant had quarantined twice under different circumstances and in different states.∗∗NT participants were quarantined in a repurposed designated quarantine centre, not a hotel			South Australia	3	5
			Queensland	7	12
Phase 1: Quarantined between March and June 2020Phase 2: Quarantined between March and July 2020 ​at two hotels in MelbournePhase 3: Quarantined between September 2020 and January 2021

The SARS-CoV-2 pandemic was the context for this study, both in subject and timing. At the beginning of the study the interviewers and many of the participants were subject to movement and mixing restrictions as Australian states and territories attempted to curb the spread of COVID-19 in the (non-returned traveller) community. Such mass lockdown had not been anticipated when the study was conceived, and rules governing quarantine and restriction of movement were in flux. Beyond a broad anticipation that MHQ would be difficult for some, we did not approach the study with any particular expectations about what we would find. We heard very similar information from participants across place and time, but the expressed impact of quarantine experiences varied considerably. Some of the interviews were difficult and participants became emotional; conducting interviews by Zoom meant that efforts to provide the type of embodied care that would ordinarily accompany sensitive interviews – a cup of tea, passing a tissue – had to be modified. A small number of participants needed assistance with technology and sought this from other people in their homes (partners, grandchildren). The authors reflected on how conducting interviews in lockdown and via Zoom might differ from previous research involvement; experiences from and reflections on this study contributed to a paper published elsewhere (Carter et al., 2021). It is also worth noting here that many participants expressed that they wanted us to do something meaningful with their experiences, that they hoped change might occur as a result of talking with us. The interviewers and study documentation were very careful to manage this expectation, but it is an indication that the issue of MHQ is morally and normatively important to people who participated in our study.

Analysis

We used a reflexive thematic analysis approach to the interview study (Braun & Clarke, 2019). Our initial research question was very broad: how did people experience mandatory (hotel) quarantine in Australia during the COVID-19 pandemic? BH and JW regularly met to discuss interviews, and both contributed to a rolling memo used to describe impressions and patterns. We both coded all interviews and initially coded inductively using broad brush topics. As we continued to conduct interviews we added and refined codes; as codes were further developed we recoded earlier interviews for consistency. We developed themes based on patterns of meaning we identified through coding and discussion. Working collaboratively was not for the purpose of agreeing themes as such; underlying reflexive thematic analysis is the role of the researcher in thematic development. Rather, we used each other's close understanding of the data to refine the themes that each researcher had identified as central to participants' experiences of MHQ.

The normative analysis of the empirical findings was the result of reading and discussion. We familiarised ourselves with ethical arguments for and against the use of quarantine in public health emergencies, particularly as they pertained to SARS in 2003. We considered how participants' reports of their time in quarantine (and, sometimes, their time after quarantine) reflected ideas of what sacrifices can reasonably be expected of individuals as they comply with requirements for others’ benefit.

Results

Participants generally expressed support for the need for quarantine and felt that they were making a useful contribution to Australia's COVID strategy. Exceptions were those people who had recently recovered from COVID-19 infection or who had travelled from locations where there was no COVID infection; these participants felt they did not pose a public health risk. Phase 3 participants, who were subject to payment for quarantine, were mostly similarly accepting of a charge.

Particularly in Phase 1 interviews, participants were in a state of uncertainty that was unrelated to hotel quarantine. Many had been required by their employers to return to Australia with only a few days' notice for an undetermined period. Those participants had left apartments and pets and, in some cases, domestic partners and hoped to be able to return to their lives overseas after things had calmed down. It can be difficult, more than a year later, to recall the fundamental uncertainty of the first months of the COVID-19 pandemic. For these participants, it was not only not knowing what the pandemic might bring, but not knowing what kinds of life decisions would have to be made in the weeks and months to come. Similarly, many Phase 3 participants had arrived in Australia after a long period of stress and heightened uncertainty around their return travel. They spoke of cancelled flights and having to live with bags packed so that they could leave to take a flight opportunity at a day's notice.

There has been considerable inconsistency in hotel quarantine conditions. They vary from state to state, facility to facility, and day to day. Some inconsistency is built into the quarantine process as a matter of normalised practice, some the result of a lack of care, and other instances are likely the result of using facilities that were not developed and staff who were not trained with quarantine in mind. Inconsistency led to considerable uncertainty. That uncertainty was at the heart of many descriptions of quarantine was initially something of a surprise. MHQ is, on the face of it, the epitome of certainty: people are taken to a hotel room, they are provided with necessities, and released after 14 days. Yet lack of information and resulting destabilising uncertainty was at the heart of many of the more difficult accounts of MHQ. In this section we describe how information was withheld, or perceived as such, and the impact of uncertainty on participants.

Withholding of information, actual and perceived

Uncertainty began as travellers left the airport via a bus which would take them to their accommodation. Most participants reported that neither the authorities nor the bus driver would tell travellers which hotel they were to be quarantining in. Participants who were familiar with the city of their arrival reported trying to make sense of the route they were taking in order to predict where they would spend the next 14 days; some said it became a game among bus passengers. Many reported being upset or anxious on the bus journey from the airport to their destination, particularly those whose expectations of different hotel conditions had been shaped by information they had read in Facebook groups dedicated to Australian MHQ. Diana, who quarantined in central Sydney, summarised the experience:

People are kind of talking to each other like, “I heard this, I heard this, I know that if you go to the front of the bus, you get into a better hotel, my friend had this experience, she had a balcony, they had this, this person struggled” and I think that kind of fosters a bit of a tense feeling in the air. And they don't tell you where you're going. Even the driver says “I don't know where we're going”, even though he's the driver and he's driving you somewhere. (Diana, NSW, Sep 2020)

This experience was repeated by participants over time and place, raising the question as to whether information was withheld as part of routine procedure.

In phases one and two of this study, COVID testing was available on request for quarantined people who reported symptoms. By phase three, two tests were mandatory (one near the beginning of the stay and one on day 10–12, depending on the location of quarantine). In another example of withheld information, many phase three participants said that they did not receive negative COVID-19 test results and that they were told that no news was good news. Participants reported finding themselves spending an indeterminate amount of time post-test waiting for a phone call or a knock at the door that would herald an unknown fate.

They say to you once you've had the test, “if we don't call you then you're fine”. That creates an enormous amount of anxiety […] because then they do call you every day anyway. So as soon as the phone rings, whether it's about anything, you're completely paranoid and stressed. Is this the moment I find out I'm positive? (Bernadette, December 2020, NSW)

Participants reported that their anxiety about not knowing their COVID status was compounded by not knowing what happened to returned travellers who tested positive. A fear of the unknown – where they would have to go, how much longer they would have to be quarantined, whether or not they would be allowed to keep their belongings – exacerbated anxiety surrounding the test reporting policy. Renee, who had quarantined at a designated quarantine facility, described seeing someone being “carted off”, she assumed because of a positive covid test, and said “we didn't know where they got taken to … that was a bit traumatic. So that's the dystopian fear, when the golf cart comes, it's like a Handmaid's Tale.” (NT, Jan 2021). For some participants, these uncertainties compounded feelings of anxiety, distress and having lost control.

Unclear, incorrect, inconsistent information

Other uncertainties appeared due to a lack of policy or coordination or poorly trained staff. While MHQ was set up under emergency circumstances, processes to ensure that quarantined travellers received sufficient reliable information had not been prioritised by the time we finished interviewing in January 2021. We heard the same frustrations over time, remarkably similar tales in April 2020 as in January 2021. With few exceptions, for example, participants reported not knowing when they were allowed to leave quarantine. This was variously because they were not told, or were given unclear or conflicting information. There was confusion over when the 14-day stretch began and what time it ended. This uncertainty caused considerable practical difficulty for people trying to make onward travel arrangements to a final destination and emotional difficulty for people who wanted certainty. Some of the stories related to misinformation about leaving quarantine were almost comical. Eva recounted that:

Even on the day I was let out, the security guard came up, he said “right you can come down and sign your release papers”, and I got down there, and the woman […] said “oh, no, you can't go … no, no, you'll have to go um, no, no, you can't go till tomorrow”. And so back, I thought “oh, well, here we go, another day”, you know, “suck it up”. And the security guard took me back up and he said that “she was the one that five minutes ago sent me up to get you”. The same person. Anyway, back, then we get up there, and he gets a call on his um, walkie talkie, “no, no, bring her back”. And I just laughed, and he said “well, you're the only one that's laughing here.” (VIC, April 2020)

Jim recounted a long story involving various government agencies and hotel staff, and ended with:

I think we finished with six or seven different phone calls telling us you know, what was gonna happen and how it was going to happen, and not one of them was remotely near what eventually occurred. (VIC, April 2020)

While the organisational chaos was described laughingly by Eva, and as an irritation by Jim, Danny and Lloyd reported that they found it profoundly difficult:

The hardest thing of all for me was the uncertainty of when I would be discharged. (Danny, NSW, Dec 2020)

The hardest part [of quarantine] was, was not having a clear plan or policy, or understanding what, what was gonna happen next … It was the lack of knowing what was next that really did my head in.” (Lloyd, NSW, April 2020)

One participant suggested that not giving a clear date and time for leaving quarantine was a deliberate strategy, to absolve agencies in charge from blame or liability if travellers made onward travel arrangements that they were unable to take up due to changes in quarantine requirements.

Rules were inconsistent across hotels, states, and time (Coate, 2020). They were inconsistently applied by whomever the participant spoke to on the telephone, or whoever was on shift that day. There were exceptions. In the third phase of interviews, some participants reported experiences that reflected an effort on the part of individual hotels to communicate effectively and consistently with returned travellers. For the most part, however, this did not happen. More commonly, participants expressed considerable frustration - it's like you're at the will of whoever is pulling the strings at that moment. (Isobel, VIC, June 2020) – and anger – I got more and more worked-up like, ’cause I just, no-one was giving us answers […] And I, I went out, and I screamed, you know, and I swore. I said, you know, “What the fuck? Who the, what the …” you know, “Somebody fucking answer me here!”. (Lloyd, NSW, April 2020). While reactions to ever changing rules differed, talking about not knowing was a constant refrain.

Uncertainty in the built environment

Finally, uncertainty was introduced via the built environment of MHQ. Not knowing what was happening to others in the same situation was reportedly very stressful for many of the participants who were quarantined alone. They were not isolated from electronic communication; all of the people we interviewed had a smartphone or tablet they could use to be in contact with others at any time. However, participants could not see others in hotel quarantine. They seldom heard others in quarantine, a situation described as “eerie”. Those who did report hearing others described distressing situations (yelling in anger, screaming in fear, calling for help). Because they did not know what was happening, they worried. Some reported seeking reassurance from hotel workers that others, strangers whose outburst they had heard, were alright.

“We heard screaming from the room across the hall from us. It was just, it was really hysterical, scary screaming […] Begging for help. And um, the security guard wasn't letting her come out, um, and wasn't going in to help. Um, and was just telling her to wait for, to wait for the nurse to come up, and um, she was just, oh, it was just a horrible sound. She was just screaming saying “he's losing consciousness, please, please help”. And um, I wanted to go out there and help but it was the security guard who wouldn't let us out. That was really traumatic actually.” (Kay, NSW, Dec 2020)

Some also described a panopticon-style assumption that they were always watched. They could not see the corridors outside their rooms but assumed the 24/7 presence of quarantine enforcers that made them reluctant to open their doors and remain compliant with rules.

Minimal efforts make a difference

We mentioned exceptions: small efforts made by some hotels to communicate with people in quarantine were received with gratitude from participants. Examples of this included posting information under the door about the following day's food, which enabled people to make decisions about whether or not to make alternative arrangements (e.g. order delivery if they did not like the food on offer).

I'll tell you one good thing the hotel here did do, they published the menu of food that's coming so you could actually see what your next few meals are gonna be and plan ahead a little bit. That was a good touch. And I guess that, giving a little bit of framework, so you have a little bit of sense of what your structure looks like. (Patrick NSW Dec 2020)

Having information written down also made a positive difference. While not foolproof, written information was described as more secure and more likely to be correct. Some hotels also made greater efforts and set up WhatsApp or Facebook groups to facilitate the transparent sharing of information between and among the hotel and people in quarantine; this was appreciated by participants whether or not they chose to actively participate in the groups.

Uncertainty led to a loss of power

Powerlessness was created or exacerbated by insufficient and inconsistent information and rules that were described as inexplicable or irrational. Participants' reported experiences of uncertainty are about more than just not knowing. They felt that the apparent withholding over information was a (sometimes deliberate) ploy to deprive them of agency and power. Rhoda, for example, said “So this is, this is how you were played. How to intimidate and yeah, put you off balance. It was constant. It was constant. (VIC, April 2020). Martina (NSW, Sept 2020) described the result of the uncertainty inherent in her quarantine experience as “becoming sub-human”. Others used variations on this term – “not a true citizen”, “dehumanising”, “zoo animal”, “criminal”, “prisoner”, “inmate”, “just a number”. Participants who described a loss of agency tended to describe an initial period of resistance – shouting in the corridor, crying or getting angry with someone on the phone – but as time progressed, they moved towards acceptance. Patricia summarises a typical scenario: “At that stage I just went, “It's just not worth it.” I got really upset the day before […], and I just thought, “It's, you just have to accept it.” And so we just did everything that they told us to do and, and didn't really have any more outbursts or cries on the phone, or anything. It was what it was.” (March 2020, NSW).

Participants reported a realisation that they could not be their usual selves in MHQ because, for this cohort, their usual selves had relatively high levels of control over their day to day lives. As Maeve (NSW, Dec 2020) put it, “because you didn't have much information you didn't feel like you were you anyway”. This realisation led, for most, to a high level of compliance. They stopped asking questions and accepted that nothing they did could change their current circumstances. Even the participants who had expressed the most anger and frustration at the situation described a capitulation by the end of the quarantine period.

Participants' reports evoked quarantine not as ‘luxury’ hotel surrounds but as a carceral space. Comparisons with prison and detention were common. This was undoubtedly compounded by the spatial dimension of MHQ – the large majority of participants were not allowed to leave their rooms at all in the 14-day period and most did not have opening windows – but was attributed to an agency deficit produced by a lack of information and the interactions with the system. Bernadette sums this up: Yes, you're in a hotel, and the bed is comfortable and all that, but the psychology and the way that people are interacting with you, it feels the same as being in detention. (NSW, Dec 2020).

Lack of/withholding information was sometimes described as a deliberate strategy, and sometimes as the result of chaotic organisational and staffing measures. Participants reported a connection between not knowing what was happening to them with powerlessness and a loss of agency. We saw a pattern of angry, frustrated or upset resistance followed by resignation, acceptance and compliance. In the next section we explore the relationship between information withholding and power, and whether induced powerlessness fits with the ethics argument that quarantine is experienced as a “small cost” that is morally obligated for the greater good (Giubilini et al., 2018).

Discussion

Mandatory hotel quarantine takes place in a context of significant power imbalance. Returning to Australia continued to be difficult throughout the duration of MHQ and, depending on their port of arrival, people rarely have any choice about their quarantine conditions (exemptions are possible but infrequently granted). Instead, they are required to participate in a system with uncertainties and inconsistencies, as we have documented in our research. A lack of relevant information in contexts characterised by unequal distributions of power widens that gulf. People who have minimal control over their quarantine environments must add not knowing to the list of burdens that they face on arrival.

It is unlikely that information is withheld as a matter of policy, but that it is experienced as such is damaging to the individuals concerned and risks undermining trust in government agencies. Communications in the face of uncertainty and rapidly changing evidence are very difficult to get right, but it is crucially important to do so. There are practical reasons that might be underpinning the non-provision of information. There is a large amount of social media commentary online about different conditions in different quarantine locations; it may be that quarantine locations are not divulged because officials wished to avoid dissent or refusal. Regarding test results, only a very small percentage of people tested in quarantine were positive and in the absence of an automated system, phoning everyone who was negative would have taken substantial human resources. Both such examples could be managed with some thoughtful communications. It is likely, however, that careful decisions are taken by well-intentioned officials who are several layers of communication away from the often poorly paid and inadequately trained people who have to carry them out.

Quarantine is institutionalised separation from the rest of the community. It can arguably be conceived as a total institution, per Goffman, because it is all encompassing (albeit brief): people in quarantine must live for a period of time, cut off from wider society, according to a set of formally administered rules and under surveillance (Goffman, 1961). Quarantine in 2021 in Australia is not socially closed, because technology permits electronic communication with the outside world, but the theorised relationships between the managed and the managers display many of the characteristics seen in our data. Jones and Fowles describe it like this: The managers have power, and social distance is their weapon. They exercise this most tellingly in withholding information, so that the managed exist in ‘blind dependency’, unable to control their own destinies (Jones & Fowles, 2008). The effects of living in a total institution related to an information deficit – and we will not pretend here that 14 days is similar to the asylum or prison terms assumed in Goffman's original theorising – were similarly mirrored in our findings, though perhaps not as acutely. An effect of the total institution is that people inside them have compromised agency, “that [they] perceived themselves to be powerless, because of the ways in which their erstwhile identities were ground down” (Scott, 2010). Participants reported feeling that information was withheld with the intention of keeping people in quarantine submissive or compliant. The ‘managers’ in the relationship were amorphous – responsibility was not placed on any one individual or institution. Rather it was experienced as a sort of control. We do not suggest that MHQ is or is intended to function as a total institution, but that for many of the participants in this study it was how it was experienced.

Uncertainty in situations where one group is, to some degree at the mercy of another, is not uncommon. Along with resulting diminished agency, it is central to the experiences of people living in immigration detention (Turnbull, 2016), of people experiencing homelessness (Anonymous, 2021), and people living with food insecurity (Coates et al., 2006). Living with uncertainty and reduced agency is less likely, even for 14 days, to have been a familiar experience for this study population, who were a comparatively privileged, mobile, literate group, likely to have had limited reliance on government services to meet their needs. They may also have not been familiar with the feeling of being treated as “sub-human” (per reported results) by the people who make decisions about their outcomes. Arguably, withholding information in hotel quarantine or not prioritising its accurate and easy transmission was a violation of this population's norms and values. The corollary of this is not that it is acceptable procedure in groups for whom it is normal. It is that where a deliberate or systematic lack of information occurs, its accessible dissemination should become a priority.

Restriction

Now we turn to how Australian style MHQ fits with two dominant recurring requirements in the ethics of quarantine literature – least restrictive means, reciprocity – for its ethical justification. The phrase ‘least restrictive means’ or ‘least infringement’ is generally understood as a requirement to maximise the amount of liberty within proposed actions (whether in terms of an overall ethical judgment or as a means to achieving a particular goal). There are alternatives to hotel-based quarantine. Some countries use technological monitoring to manage mandatory at home quarantine (e.g. Singapore, Hong Kong, South Korea) as a less restrictive alternative to state-appointed quarantine facilities; this is sometimes risk-stratified (Reuters, 2020). Others have different quarantine requirements for travellers exposed to different levels of risk or according to vaccination status (Ministère de l’Europe et, 2021; Ministerodella Salute, 2021). It is not clear whether or not these options are as effective in reducing spread of infection; it seems feasible that the level of security and elimination of choice in hotel-type accommodation may be necessary to achieve the low levels of COVID infection that are the goal of this public health intervention. If a highly controlled environment is justified, however, it does not follow that choice in all its aspects should be removed. It is reasonable that a person who has travelled from a location with SARS-CoV-2 circulating in the community not be allowed to mix with the general public in Australia until any risk of transmission is deemed to have passed. It is not reasonable to fail to provide that person with information about when and how they can leave, about the results of their COVID tests, about what food they will be given that day. Without this information people are unable to function in the ways that they are accustomed to and their agency is reduced. Diminished agency – feeling sub-human or criminal – is not a necessary or useful part of keeping COVID from spreading.

Reciprocity

Similarly, the ethics literature about mandatory quarantine uniformly includes reciprocity as a requirement for ethical justifiability. It could be argued that providing food and shelter (in the form of a hotel) is reciprocity enough, though this argument became much less convincing after the required payment was introduced. The premise that underlies reciprocity is that people in quarantine are making a sacrifice for the benefit of the wider public and that this liberty-based sacrifice should not accrue additional burdens. It became clear in our study that the provision of food and a comfortable bed was not sufficient to ease the burden of quarantine. In addition to practical considerations, reciprocity should also take into account the importance of managing quarantine processes so that they are in line with people's norms and values, by minimising their emotional burden while in quarantine. The avoidable and potentially dehumanising effects of ignorance while in quarantine mean that the sacrifice required of people is not experienced as “small”, per Giubilini et al.’s calculus. As experiences of quarantine have widened to encompass the threats posed by the COVID-19 pandemic, so too should the ethical considerations used in the discussion of quarantine. The burdens of MHQ – emotional, financial, practical – and their distribution are broader than was envisaged in pre-COVID assessments of ethical justification of quarantine and our study suggests that some were unintended.

We have focused on the importance of clear, respectful, nuanced communications. Developing and enforcing consistency in quarantine conditions would ease much of the uncertainty experienced by people in quarantine. Australia's federal system of government makes this a more difficult proposition than it is in countries with centrally-run quarantine programs (e.g. New Zealand) (Ministry of Business and Inn, 2020). Federalism commonly sees blame- and cost-shifting between Australian states and territories and the Commonwealth on many issues, and interjurisdictional cultural and political differences are often played out to the detriment of its citizens. There have been official recommendations to standardise conditions in MHQ (National Review of Hotel Quarantine, 2020), a move that would make expectations and communications easier and that could minimise the autonomy-limiting experiences found in our study. Improving the quality of information and its delivery to people in quarantine could go part-way to easing the burdens they experience. Mental and emotional load in quarantine must be included in considerations of reciprocity and restriction; to ignore these burdens lessens the ethical justifiability of MHQ now and in the future.

Limitations

People who participated in interviews may be more likely to have done so because they have had a meaningful experience, either positive or negative, a situation that applies to interview studies more broadly. We are also aware that we are reporting the experiences of a subset of Australians overseas who can afford to return – airfares during the study period were very expensive and scarce and quarantine is paid by the traveller. For many, quarantine is a liminal space that comes at the end of a long and stressful period of time and may well be the beginning of another. We cannot say that the experiences we report are typical, though we conducted a large number of interviews and heard strikingly similar stories across phase, place and time.

Conclusions

A review of Australia's hotel quarantine system published in late 2020 begins: “Hotel quarantine is difficult to endure, particularly for vulnerable people.” (National Review of Hotel Quarantine, 2020) Australia's current Prime Minister has said that quarantine in some form will be a long-term proposition. Continuing to use hotel rooms for quarantine indefinitely is difficult to justify, for practical and ethical reasons. The use of hotels for quarantine has been criticised on efficacy grounds, with a number of infection leaks being attributed to air conditioning systems that allow communication between rooms and common spaces. We have found that hotel accommodation, even in 5-star hotels, needs to be supplemented by clearer provision of information to avoid producing unnecessary harms that create impositions and add to burdens of newly arrived travellers. The very limited literature about experiences of MHQ in Australia and other countries suggests that the difficulties described by this cohort are not unique (Dinh et al., 2021).

In the context of Australia, where relaxing mandated hotel quarantine would likely have led to the introduction of (absent at the time) community spread of COVID-19, we consider that some form of mandatory supervised quarantine in an assigned location is likely justifiable. As vaccination levels increase in Australia, this calculus is changing.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.