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Passengers Disembark Diamond Princess Cruise Ship After Quarantine Ends Photo by Tomohiro Ohsumi/Getty Images

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Coronavirus-contaminated cruise ships mirror the global crisis

Cruises aim to be frictionless, but disruptions from land burst that bubble

Cruise ships are, depending on your preferences, floating nightmares or simple, resistance-free retreats. They isolate travelers from the world while offering idealized versions of cities on land. But problems ashore — like a massive coronavirus outbreak — sometimes sneak aboard.

Thousands were quarantined off the coast of Japan on board one cruise ship, the Diamond Princess, after the virus was detected in someone who’d recently disembarked. They weren’t allowed to leave until February 19th. The virus rocketed through the population of the boat, and now, over 600 people connected with the ship are sick, and two passengers died.

Despite efforts to build a tightly controlled-but-effortless environment on cruise ships, cracks show easily when something like an infectious disease takes hold on board. The coronavirus outbreak is affecting other ships, too: the World Dream was quarantined off of Hong Kong for four days. Royal Caribbean and the Norwegian Cruise Line aren’t allowing passengers who have passports from China, Hong Kong, or Macao, or who have recently traveled to China on board for scheduled trips. The Westerdam was turned away from five countries before it was allowed to dock in Cambodia.

The new coronavirus breaks down the promise of the cruise ship as a bubble of independent banality of the open ocean. As the virus — and fears of the virus — spread, the problems balloon, and the bubble bursts. And it shows how that environment reflects the medical, political, and cultural effects of epidemic disease.

Accelerating outbreaks

Passengers Disembark Diamond Princess Cruise Ship After Quarantine Ends Photo by Takashi Aoyama / Getty Images

Ships have been targets for disease control for centuries. In fact, the combination of horrifying illness and ships gives us the modern word “quarantine.” When the Black Death terrorized Europe in the 14th century, the Venetian trading colony Ragusa didn’t close itself off entirely. Instead, in 1377, the city passed new laws for visiting ships. If they came from places where the plague was spreading, they were required to stay anchored offshore for a month to prove that they weren’t carrying it. Eventually, the period was extended to 40 days and called a quarantino from the Italian word for 40.

The Diamond Princess wasn’t quarantined for anything close to 40 days. But both the current Japanese government and 14th century Venetian authorities wanted to prevent passengers who might be carrying disease from spreading it to land — the fact that diseases might spread around the ship during that time wasn’t the main concern.

During the two-week period when it was isolated in port, the Diamond Princess had the largest concentration of people infected with coronavirus outside of mainland China. The ship’s trials started when an 80-year-old passenger who had already left the ship tested positive for the coronavirus on February 1st, six days after disembarking in Hong Kong. The ship rerouted its scheduled trip and returned to the port city of Yokohama, Japan, and passengers were confined to their rooms as health screenings began.

On February 4th, the first day the Diamond Princess was under quarantine, 10 people out of 3,711 passengers and crew tested positive for the virus. By February 8th, there were 16. The numbers ballooned from there: to 135 cases, 174 cases, 218 cases, and up to 454 by February 17th. The sick left the ship and were taken to Japanese hospitals, as remaining passengers watched from their stateroom windows. By the time the quarantine lifted on February 19th and patients without the virus were allowed to disembark, at least 621 people linked to the ship had tested positive for the virus.

The escalating case numbers aboard that ship made it appear as if it was “facilitating transmission,” tweeted Alexandra Phelan, a member of the Center for Global Health Science and Security at Georgetown University.

Cruise ships, with their emphasis on communal dining and group activities, are notorious for being an incubator of infectious disease. Norovirus, the highly contagious virus that causes a stomach bug, is often referred to as the “cruise ship virus” because of how easily it spreads through the tightly packed environment on board the ships. In 2008, for example, 196 people became ill with the virus on a cruise ship traveling through the British Isles, and most fell ill after spending time in the most highly trafficked areas of the ship. Germs sit on shared serving utensils, bocce balls, and handles. People sweat and cough on neighboring lounge chairs or while on deck. And who wants to stay in their tiny cabin when there are so many things to do? Cruise ships can easily help pathogens spread from person to person.

That’s particularly true if proper infection control procedures aren’t being followed, which experts say was the case on the Diamond Princess. Passengers were confined to their cabins during the quarantine, but crew members kept moving around the vessel — possibly spreading the bug around — and passed materials, like paper forms, in and out of passenger rooms.

As much as the quarantine was a public health crisis for those on board, it also could function as a miniature experiment: the ship functions as a small-scale model of the larger outbreak, although it’s under accelerated, artificial conditions. Scientists on Twitter are calling for a close look at the way symptoms developed in sick passengers over time and how disease progressed in a group that tested positive for the virus but didn’t appear to be ill. It’s not clear if an investigation is being conducted at this point, but the data from on board the ship would likely be valuable.

Diamond Princess Cruise Ship Remains Quarantined As Coronavirus Cases Grow
Crew members work on board the Diamond Princess cruise ship as the ship arrives at Daikoku Pier on February 12th, 2020.
Photo by Tomohiro Ohsumi / Getty Images

Exacerbating inequities

Though passengers on the Diamond Princess were stuck in their cabins during the quarantine, they were stuck with satellite TV, a selection of movies, activities for children, and food delivered on schedule. Those meals are delivered by the crew who are still at work serving the international passengers and still moving around the virus-laden ship.

Continued work means crew members are traveling through the ship and coming into contact with passengers. At least a few dozen contracted the virus. Because they’re also in regular contact with each other and live in close quarters, some worry they were at a higher risk of passing it around. (Unlike passengers, they weren’t isolated from each other.)

“We all eat together. There are many places where we all are together, not separated from each other,” crew member Sonali Thakkar told CNN. “Especially when we sit in the same mess hall and eat together, the place where it can spread very fast.”

Cruise ship companies like Carnival Corporation, which owns the Diamond Princess, often register their ships in countries with permissive labor laws. Working conditions are reportedly bad, pay can be low, and there’s very little job security. The lowest-paying and most challenging positions on cruise ships are often given to people from lower-income or developing countries.

In the world beyond the bulkheads, the vulnerable always see a disproportionate burden of infectious disease. Wealthier countries and the wealthy, in general, have the resources to protect themselves more effectively against disease and to treat it if it appears. That dynamic is playing out on board the ship, with a greater (though still apparently insufficient) level of protection awarded to passengers and higher-status crew members who sometimes have their own rooms and more space. “The crew is scared to death,” Arnold Hopland, a doctor vacationing on the ship, told Politico. “They’re frightened and they’re packed together in tight quarters, working elbow to elbow.”

International waters

Policy decisions made during public health emergencies are based on more than just health information. The choices are based on politics, economics, and to mirror those made by others. As countries negotiate their responses to the outbreaks, the geopolitical jockeying also impacts cruise ships — and the people on board.

The Westerdam cruise ship, for example, made a stop in Hong Kong, which has a higher number of cases than most places outside of mainland China. When it came time to return to port, it had trouble finding a place to go. The ship was turned away from Thailand, Japan, Taiwan, the Philippines, and Guam over concerns that its passengers would bring the new coronavirus ashore. Eventually, Cambodia gave the ship permission to dock. “The coronavirus is making ports more sensitive to illnesses,” says Ross Klein, who studies the cruise ship industry at Memorial University of Newfoundland.

CAMBODIA-CHINA-HEALTH-VIRUS Photo by Tang Chhin Sothy / AFP via Getty Images

The Westerdam’s experience reflects worldwide decisions made in response to the outbreak. Despite the World Health Organization’s recommendations that countries not restrict travel and trade, the policy response has trended toward isolationism: the US instituted travel bans, Russia closed its borders, New Zealand is not allowing foreign nationals traveling from China to enter.

Cruise ships occupy a unique geopolitical position: they operate as their own entities and avoid being subject to the laws and jurisdiction of countries with heavy regulatory pull. The new coronavirus, though, highlights their dependence on structures and policies on land. Crew and passengers on the Diamond Princess, for example, were subject to quarantine decisions out of Japan. And now that they’re allowed off the ship, they’re beholden to the regulations of their home countries.

The United Kingdom said it’s flying its citizens out, after facing public pressure, and quarantining them again back home. Other countries, like Australia and India, made similar calls. The US Department of State brought back one group of people, but the Centers for Disease Control and Prevention then backtracked, saying the remaining citizens who were on the ship (around 100 people) will have to wait 14 days virus-free before they can return Stateside.

As the global crisis continues to unfold, it’s challenging to follow the complex web of new scientific information and policy changes — and it’s harder still to keep track of how and why new developments happen. The Diamond Princess and other cruise ships offer pockets of the crisis that showcase the overall dynamics of viral transmission, class division, and international decision-making. They show the public health machine in action.

It’s a machine that the passengers who streamed off the Diamond Princess on Wednesday will stay ensnared in, with the notorious distinction of having endured the largest new coronavirus hotspot outside of mainland China. Reality intruded on their vehicle for escape, and it’s disembarking with them, too.

There’s a lot of uncertainty about what’s next. Passengers worry about restrictions they’ll face on land, additional quarantines, and trips back home. “It’s a big concern,” Diamond Princess passenger Kent Frasure told NBC News. “Am I allowed to walk the streets of Tokyo? Can I walk into a Pizza Hut or something? Can I go into this sushi place or are we stuck again for 14 more days in some sort of housing?”

Their experience still matches the larger outbreak. Despite the best efforts of leading scientists, the new coronavirus is still a global public health crisis, and the future is unpredictable.

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