There has been much discussion among friends, on social media and in the press about the challenge to mental health posed by Hong Kong’s mandatory 21-day quarantine. A new academic paper, the first to take a scientific and qualitative approach to the world’s longest mandatory quarantine, concludes it is associated with negative psychosocial consequences, some of which are long-lasting. “The overwhelming feeling is that in the pursuit of protecting humans from the illness there has been a loss of sight of humanity,” says its author Dr Judith Blaine, a long-time Hong Kong resident and a research associate in South Africa’s Rhodes University Psychology Department. Early on in the pandemic, Blaine joined some of the quarantine support groups and heard first-hand the anger and feelings of isolation. She determined to take a qualitative approach to the subject and searched for an ethical framework for pandemic planning. “A lot of people are saying [the quarantine] is inhuman, unethical. If approached from a scientific point of view, it removes the emotion,” says Blaine. To create awareness, Blaine says, “I tried to do the paper quickly and get it in a peer-reviewed journal.” Quarantine: its past and future, and the importance of human connection When “Exploring the Psychosocial Consequences of Mandatory Quarantine During the Covid-19 Pandemic in Hong Kong” was published in Psychology and Behavioural Sciences in late May, Blaine submitted the paper to the office of Chief Executive Carrie Lam Cheng Yuet-ngor, the head of Hong Kong’s government. She received an acknowledgement but has heard nothing further. Blaine’s paper lays out the challenges to mental health , and details how some people experience post-traumatic stress disorder (PTSD), depression and insomnia long after it ends. She calls for psychological support to be made available to people during and after quarantine. Many participants mentioned lingering physical effects such as back problems, muscle ache and brain fog, but more common were lingering feelings of fear, anxiety, anger, exhaustion, lack of energy and difficulty in social integration. Some are still experiencing PTSD, depression and insomnia . Others expressed feelings of anger and resentment at the policymakers for imposing this “punishment” on them. One interviewee, who was sent to hospital and found the experience overwhelming, told Blaine: “By the time I got out of hospital, I was so psychologically scarred and terrified, I didn’t want to go anywhere. I didn’t want to go anywhere where anybody could potentially pick me up and take me back again.” For most participants, it was the lack of openness and transparency that created adverse psychosocial effects. For her paper, Blaine settled on an ethical framework drawn up by the New Zealand National Ethics Advisory Committee, “Getting Through Together: Ethical Values for a Pandemic”, published in 2007, after the severe acute respiratory syndrome (Sars) epidemic from late 2002 to 2004. That work identified five factors: Inclusiveness: “Including those affected by the decision, all communities, you need people to buy into the whole measure,” says Blaine. Openness and transparency: “The decision should be open to scrutiny and the basis for the decision explained to the general public, then more people are likely to buy into the programme.” Reasonableness: Ensuring it was “based on scientific evidence and principles. Most people will agree there is a requirement for quarantine, but are the measures reasonable?” Blaine says. Responsiveness: “Perhaps decisions need to be revised, not just buying into a long quarantine without any revisions,” she says. People just want to be heard and have a sense of autonomy in the decision-making process Judith Blaine, long-time Hong Kong resident and study author Accountability: “Ultimately if people understand why the measures are in place and actually buy into the whole concept of quarantine, you are going to mitigate the psychosocial consequences. People want to be heard and want to feel autonomous in their decision-making process,” says Blaine. Blaine received 130 responses from people for her study and says all those she interviewed felt the 21-day quarantine was unreasonable. Based on the interviewees’ data, none was given sufficient information about why a three-week quarantine was necessary. “We are social creatures,” she says. “To have social deprivation for 21 days is really against the very being of being human.” Surviving the world’s longest hotel quarantine in Hong Kong Blaine’s paper suggests ways to help mitigate quarantine’s negative effects. “You can include counselling services, hotlines,” says Blaine, who notes that no one took into account whether a person going into quarantine had a history of mental illness. “There is no taking into account people’s individual needs, it’s a blanket measure with little support.” In Australia, she said those who are vulnerable or who have a previous mental health condition are assigned a different kind of accommodation, a flat with windows that open, and from which knives are removed. And everyone in quarantine receives a daily phone call from the government to check in on them and ask how they are coping. The WHO’s Hong Kong representative was approached for comment on Blaine’s paper, but did not respond. Nor did three other international health organisations. However, WHO director-general Tedros Adhanom Ghebreyesus said in March 2020 that “all countries must strike a fine balance between protecting health, preventing economic and social disruption, and respecting human rights”. The findings of Blaine’s paper on the Hong Kong quarantine are echoed in academic research internationally. A paper published in The Lancet last year by Samantha Brooker at King’s College, London, concluded that quarantine periods should be short in duration and that most of the adverse psychological effects come from restricting liberty. “Voluntary quarantine is associated with less distress and fewer long-term complications. Public health officials should emphasise the altruistic choice of self-isolating,” wrote Brooker in The Lancet . What you need to know about Hong Kong’s quarantine rules Daisy Cheung and Eric Ip of the University of Hong Kong’s faculty of law last year published a paper in the Asian Bioethics Review , “Covid-19 Lockdowns: a Public Mental Health Perspective”. The first peer-reviewed article to take a public mental health ethics perspective in examining lockdowns, it concluded that even the strictest lockdowns are not necessarily unethical, but are prone to damage mental health disproportionately, with the vulnerable and disadvantaged populations being particularly at risk. “Extreme measures such as lockdowns and lengthy quarantine periods cannot be justified simply on the basis that they can somehow be shown to be effective in saving large numbers of lives in the short run. Consideration must be given as to how these measures can be implemented with the least possible limitation on our right to mental health. Mental health is an indispensable dimension of human health,” says Cheung. She and Ip say there is a need to incorporate ethical values in any decision-making on policy in these matters. Blaine says the negative psychosocial impact of the quarantine hinges on the way it is made mandatory and enforced without public discussion. “People just want to be heard and have a sense of autonomy in the decision-making process. If you want to mitigate psychosocial consequences, make it out as though people have a choice,” says Blaine. Like what you read? Follow SCMP Lifestyle on Facebook , Twitter and Instagram . You can also sign up for our eNewsletter here .