The standard prescription from the Centers for Disease Control and Prevention for the mildly ill to self-isolate at home is something doctors and nurses in coronavirus hot spots repeat hundreds of times each day. But there’s a devastating cost to the public policy decision: multiple families with multiple deaths.

An 86-year-old matriarch and her three adult sons in New Orleans.

High school sweethearts married for 57 years in Grove City, Ohio, and their son, who had visited recently.

Sisters in Chicago. A mother and daughter in Baltimore.

All dead within days of each other because of the coronavirus.

Amid the family tragedies come increasing calls for U.S. officials to isolate the mildly ill and infectious away from their homes — in convention centers, school gyms, anywhere else.

It’s not just a public health issue but an economic one.

Focusing restrictions more narrowly on the infected and their contacts, so that others can be freed from lockdown, has become a vital pillar of proposals to reopen the country.

The issue is especially critical in light of research that suggests genetics may partly explain the wide disparity in how people react to covid-19, with some shrugging off the virus without even knowing they are infected and others facing death.

“In a sense,” Ryan said, “transmission has been taken off the streets and pushed back into family units.”

China’s success with isolating family members separately has been held up as a model for breaking transmission chains. But images of Chinese officials forcibly taking people from their homes drew visceral reactions from many.

“We couldn’t under any circumstance do what China did,” said Thomas J. Bollyky, a senior fellow at the Council on Foreign Relations and director of its Global Health Program. “Large-scale, non-voluntary quarantines would be challenging from a legal point of view.”

Yale University’s Gregg Gonsalves, an epidemiologist, tweeted Wednesday that family separation “is a cruel overreaction and a violation of human rights.”

But other experts, such as Carl Minzner, a professor of law at Fordham University, believe isolation and quarantine can be done voluntarily, in a way that respects civil liberties. Minzner is especially worried about poor people living in dense housing, who, according to early reports, make up a disproportionate number of the infected.

“Many people,” he said, “are terrified about infecting their family members and want to self-isolate but have nowhere to go.”

Several U.S. communities recently began experimenting with isolation centers.

On April 1, Hillsborough County in Florida set up two motels for those who have suspected or confirmed infections and are concerned about exposing vulnerable family members. Wisconsin and North Carolina have done the same in their largest cities. Other jurisdictions have set up “safe” housing for first responders such as doctors and police.

Different countries, different experiences

South Korea, Singapore and Taiwan, which have been relatively successful at controlling the spread of the virus, isolated the mildly ill, while Italy and Spain, where infection rates skyrocketed, did not. Public health experts have said a steady stream of household infections may be to blame for that spike in numbers.

China’s experience may be the most instructive. The country initially ordered people to stay at home. But as infections mounted, it turned to isolation, separating those with covid-19 from non-infected people, and quarantine, separating those who had come in contact with an infected person to see if they also would become sick.

When China shut down Wuhan on Jan. 23, the scope of the lockdown was unprecedented in modern times. Flights and trains were stopped. Public transportation was suspended. All of a sudden, millions were told to stay at home.

Through late January and early February, the city’s hospitals were overrun. With intensive care units packed, people with mild illness were advised to stay home. The problem, of course, was that sick people spread the virus through households.

Some tried to keep family members with symptoms in a separate room. But the virus spread through the city’s apartment blocks. In some case, whole families got sick.

In early February, China adopted a new tactic: mass quarantine and isolation. In Wuhan, more than a dozen makeshift hospitals and quarantine centers were opened.

On a visit to Wuhan, Vice Premier Sun Chunlan ordered medical workers to scour homes for confirmed cases, suspected cases, people with close contact with confirmed cases, and people with fevers.

People who did not cooperate would be compelled into quarantine. The vice premier warned of “wartime conditions,” saying “deserters” would be “nailed to a pillar of historical shame.”

In some cases, healthy people were mistakenly sent to live in close quarters with the sick, fueling the spread of disease. In some facilities, patients languished without adequate care. Social media posts showed people being dragged away against their will to quarantine or isolation.

The opposite approach is also terrifying. Italy’s lack of isolation centers, along with multigenerational households, has been cited as a reason for its high infection and death rates.

Zeke Emanuel, a medical ethicist who was an adviser in the Obama administration; Scott Gottlieb, a physician who was President Trump’s first Food and Drug Administration commissioner; and others who have released detailed plans for how to safely end the crisis have argued that there is a middle ground.

They point to the threat of large fines and appeals to people’s sense of moral obligation to their families and communities as effective strategies used in other parts of the world to get those suspected or confirmed to be infected to leave their homes.

Harvey Fineberg, a former president of the National Academy of Medicine who now heads the Gordon and Betty Moore Foundation, has proposed that the United States consider what he calls a “smart quarantine.”

Anyone who shows symptoms would be separated in a temporary shelter until test results return. If they test negative, they would remain in quarantine and be retested at 14 days. If that second test is negative, they could return home. If they test positive, they would go into a different type of facility for care.

To be effective, he argues, the proposal must be part of a broader strategy: testing, isolating confirmed or presumptive cases, and contact tracing. Isolating the infected wouldn’t be possible in all cases. After all, scientists believe some people are asymptomatic. But it would slow down the rate of infection.

“We have seen from elsewhere, those who are most at risk are the family members of those who have been exposed,” he said.

He said many people would welcome the opportunity to shelter somewhere outside their home, provided there was adequate care.

“I think that a lot of people, when they really saw it as a way to provide maximum protection to their own family, would welcome this,” he said.

U.S. experiments

One of the nation’s first voluntary quarantine and isolation facilities opened in early April in Florida’s Hillsborough County. Housed in two motels with 362 rooms, the center provides people concerned that they could infect elderly or medically vulnerable family members a free, out-of-home option for shelter.

Iñaki Rezola, operations section chief for Hillsborough’s emergency management team, said that while the center’s main goal is to help people at the beginning of infection — when they are typically shedding the most virus and pose the biggest risk — it is also accepting patients discharged from hospitals.

Rezola said 14 people have already checked in. Referrals for a spot are made by physicians to the county’s department of health.

Rezola said guests (he emphasized that they are not patients) are served three meals a day in their rooms, paid for by the county. While no medical workers are on site, the staff is available to deliver medicine and has access to doctors via telemedicine. Each unit has its own air conditioning and heating, so there is little concern of contamination from adjacent rooms.

“Placement is voluntary,” Rezola said. “You choose to go here. No one is being kept against their will.”

On Wednesday, North Carolina announced that it had secured 16,500 hotel and dorm rooms to be used as recovery centers for those who have recently left the hospital and are possibly still infectious, and, separately, for what the state calls “shelter-in-peace” sites for first responders such as doctors, nurses and police.

The recovery centers will provide medical support such as supplemental oxygen. The “shelter-in-peace” buildings will have reconfigured HVAC systems so that rooms don’t share air; after each room is vacated, it will be sterilized with 135-degree heat for three hours to kill any virus on surfaces, officials said.

Two funerals, three deaths

Marcos Melendez wishes that such facilities existed a few weeks ago near his home in West Jordan, Utah. A Costco cashier, Melendez said he believes he was the first in his family to become infected.

The second week of March, he said, he came down with a high fever and a cough so bad that he contacted his doctor at the University of Utah via video chat. He said he was told to quarantine for 14 days and call back if he got worse. It wasn’t long before the rest of his household — his wife; two sons, ages 22 and 28; and 24-year-old daughter Silvia — were infected.

“I was surprised they didn’t take me to the hospital. I should have gone to the hospital, and I should have stayed in the hospital so I didn’t infect my family,” Melendez said.

As he feared, Silvia, who a few years ago underwent open-heart surgery because of a genetic condition, became seriously ill. What he didn’t expect was that his wife would, too. Both were admitted to the hospital. His wife pulled through and is at home recovering. Silvia died on March 28.

Just hours after her husband’s death on March 26, Brown said, her son suddenly developed a 102.8-degree fever and was having difficulty breathing.

“I know he got it from his dad. He was fine before,” she said.

Three days later, she was on FaceTime with Sonny at the hospital as medical workers were about to put him on a ventilator.

“I told him to stay calm. He was afraid. His dad died on the same floor. I begged them to be able to be in the room with him,” she said. The doctors refused because of the risk of infection, but a few hours later she got a call telling her to hurry to the hospital. By the time she arrived, he was gone.

“When we left, he was hysterical on the stairs,” Prina recalled.

The ambulance call that haunts him is one of thousands during several relentless weeks in which this region has become the world’s coronavirus epicenter. North Bergen is located at the other end of the Lincoln Tunnel from New York City on hilly cliffs, part of a constellation of densely populated, working-class cities and towns where the virus has flourished. As of Sunday, New Jersey had 85,000 confirmed cases with 4,200 deaths — and most are concentrated here in the northern part of the state.

While most Americans shelter at home, emergency medical technicians (EMTs) — who operate the nation’s ambulances — go toward the danger. Working in chaotic conditions in unpredictable environments, they are a resilient bunch trained to respond to everything from highway pileups and bar fights to people having seizures in their homes.

But operating against an invisible virus that kills so indiscriminately is different. At least 13 EMTs and 50 police officers and firefighters nationwide have died of covid-19-related complications in recent weeks. And in a pandemic that has killed mostly the elderly, a disproportionate number of the first responders who have perished have been in their 30s and 40s.

Two of the dead are this area’s own: Kevin Leiva was a 24-year-old EMT in North Bergen. Israel “Izzy” Tolentino Jr., a 33-year-old father of two, was a firefighter and EMT from neighboring Passaic. Both had second jobs as EMTs for Saint Clare’s Dover Hospital, where they sometimes worked together.

Franklin Pachay, also an EMT, was Leiva’s best friend. They met 4½ years ago as trainees and became so close that Pachay became an ordained minister online so he could officiate at Leiva’s wedding. Leiva did the same for him.

“We all know what the job is. But no one expected this,” said Pachay, 24. “Once his passing was made public, everyone — even people who didn’t work with him regularly — was upset. It’s a small community.”

In northern New Jersey, ambulance crews are almost a family business, with every one linked in some way to every other one in the region. The job pays $16.50 to $20 an hour (with an extra $10 an hour thrown in these days as hazard pay) for a 12-hour shift. It’s not enough to make a living on its own, so many of those who work in North Bergen have two jobs, some three, with other EMT services in places such as Union City, Passaic, Paterson and Jersey City. Many have spouses, significant others, siblings, cousins, parents, and aunts and uncles who are also on the front lines on ambulances or at hospitals. Most are bilingual Spanish speakers who were born in the United States or who immigrated at a young age, reflecting the area’s increasing diversity.

For many who serve with North Bergen’s Emergency Medical Services, the job is a calling.

Liz De Bari is one of the crew’s oldest, at age 44. She joined after witnessing the collapse of the twin towers on Sept. 11, 2001, from a street not far from the ambulance bay on Granton Avenue where she now works. Marco Navarro, 30, is a former Marine reservist who did a tour in Iraq. Estafania Castaneda, 29, was working at Dunkin’ Donuts when a customer suggested she consider becoming an EMT. She thought, “Why not?” and ended up loving it.

As for Leiva, he had always dreamed of becoming a doctor, says his wife, Marina, but his parents didn’t have much money and he realized he probably wouldn’t be able to pay for medical school. Then one day when he was in college, he received an email meant for someone else about a scholarship for a student who wanted to go into emergency medical services. He applied, and got it. Marina said he felt it was “an act of God.”

Unlike some medical centers where doctors and nurses are facing shortages of masks and other protective gear, the North Bergen Township has plenty because of stores it created during the Ebola panic. It has N95 masks, goggles, face shields, gowns, hats and gloves.

Yet EMTs are still somehow becoming infected.

A 30-hour shift

Officially, 47 people are on the North Bergen EMS roster. After Leiva’s death on April 7, however, three co-workers went AWOL — “just disappeared,” scheduler Gendi Santiago said. A fourth called in to say that her husband didn’t want her to work while covid-19 was still tearing through the town. A fifth broke down crying last week with two hours left to go in her shift and went home early.

Four EMTs tested positive for covid-19 and had to self-isolate.

Brigdon Campbell, 39, was one of them. When he first noticed symptoms — he lost his sense of taste and smell, a trademark of the infection — he wondered if he would die, too.

“I was like, ‘We had a good run.’ I accepted it,” Campbell recalled. But nine days later, he was feeling fine and cleared to return to work.

He thinks becoming infected was inevitable, almost a mathematical certainty based on his close contact with so many infected people. “It doesn’t matter how careful you are,” he said. “The more times you do it, the more chances you have to catch it.”

Those who remained worked back-to-back shifts as the volume of 911 calls soared from about 600 a month to more than 1,000. One particularly bad day in April, De Bari worked 30 hours straight. She said afterward that she felt as though she couldn’t breathe, even though she wasn’t sick, and she had to take time off. “It was PTSD,” she said — post-traumatic stress disorder. She said she just sat at home for two days and thought.

“I didn’t know what was going on. Everyone was dropping dead. I just wanted to be with my family. At that point, I started thinking, should I say goodbye to my parents? Am I going to die tomorrow?” she said. “Now I came to terms with it. I’m not a quitter. I’m going to keep going.”

Other EMTs are dealing with similar stress.

Navarro’s daughter was born two weeks ago at 1 pound, 13 ounces, and is still in a neonatal intensive care unit. He couldn’t be there for the birth and hasn’t dared to go anywhere near her for fear of transmitting the coronavirus. “I go visit by the window,” he said.

Campbell wears a mask when he’s at home 24/7, even when he sleeps, because he doesn’t want to infect his 2-year-old.

Castaneda hasn’t seen her elderly parents in a month for the same reason.

Following the deaths of their fellow EMTs, there was an outpouring of support from the community. The local pizzeria sent pies. School parent associations delivered bag lunches. And Starbucks offered free coffee. The Justice Department clarified that a federal program for first responders that provides benefits for the survivors of those who die “in the line of duty” will include covid-19, if it’s “more likely than not” that they were exposed during their work. Politicians from New Jersey, including Sen. Cory Booker (D), have argued that in a pandemic, it can be impossible to pinpoint the source of an infection, and that all working first responders who perish from covid-19 should be included.

The EMTs say they are grateful for the support, but don’t feel like heroes when so many are dying.

Everyone has that one coronavirus call that they think about over and over again. For Castaneda, it was the man who had collapsed on the floor, dying, with his three children, wife and mother saying prayers in Spanish and begging her to “please bring him back to life.”

“When you are treating the patient, the adrenaline is rushing, but when you get off shift, that’s when it hits,” she said. “The kids crying and screaming and screaming.”

For Pachay, it’s the 50-year-old man who suffocated in front of him. “Just watching him going from talking to you to being dead a few minutes later. . . . His wife was there. She saw everything,” he recalled.

For Prina, it’s the mounting number of DOAs, or dead on arrivals — the people dying in their homes — that make him feel helpless. In normal times, they might see one, maybe two a month or every few months. Now it’s more like six or seven a week.

The county leased two refrigerator trucks, with room for 45 bodies each, but there is so much death that the waits for pickup can be agonizingly long. Families that have money can call a funeral home to come get the body from the house, he said. Those that don’t face a nightmare. It could be one to two days before a medical examiner shows up.

“It’s just call after call after call. I have never seen anything like it,” said Prina, a former firefighter. “Every other [call] is ‘flu-like symptoms.’ I have been an EMT for 25 years. I see death all the time. I have seen some awful things. But it’s the repetition that gets me. If you go on shift now, it is a guarantee you will see death.”

Prina thought again of the 18-year-old boy and his 56-year-old father. His own son is 18. He’s 51.

“I heard they are putting people on the malaria drug and a Z-pack, which works great for some people. My friend’s father took it early on and he had a fever for one day and was better,” he said, referring to the anti-malarial hydrochloroquine touted by President Trump and the antibiotic azithromycin. (The combination, which can cause dangerous cardiac effects, has not been recommended to prevent infection but some hospitals are trying it for sick patients.) “I have a stash in my house.”

As chief of the North Bergen crew, Prina has had to make dozens of decisions, big and small, over the past few weeks that weigh heavy. Many times, he’s facing only bad choices.

In early April, all seven nearby hospitals went on “divert” status, signaling that they were too overwhelmed to handle any more patients. But Prina calculated that the next closest hospital was 20 to 25 minutes away — too far for a patient in cardiac arrest or respiratory distress. A one-hour round trip, including the time to hand off the patient, would also mean leaving others who called 911 waiting. So he ordered the trucks to take patients to the closer hospitals anyway.

Another big issue was a nearby nursing home with several dozen deaths. He did not want his EMTs going inside, if at all possible, because he thought the entire complex was probably contaminated. So he worked out a compromise: The nursing home staff members wheel patients outside so the crew can treat them there.

CPR, or cardiopulmonary resuscitation, which involves chest compressions and tends to aerosolize the virus, putting EMTs at increased risk, was another big concern.

“All the rules are different,” he said. “We do three rounds of CPR and then it’s over. They just leave you there. In the past, they would work you all the way to the hospital.”

He said the town is bringing in antibody tests so that every EMT will be tested this week to see if they have been exposed to the virus. And it has set up a mental health counseling service that will allow everyone to have up to 12 one-on-one sessions.

Reinforcements arrived at 3 a.m. on April 11, finally: six fresh-faced men and women from Indiana, all in their early 20s, hired by the Federal Emergency Management Agency, who had driven all night to get there.

“They thought they would be transporting people to the covid hospital ship,” Prina said. “They never had any idea they be doing 911, never had any idea they would be thrown into hell. Some had never done CPR. The first day, our guys were like, what the [expletive] are they doing here?”

What ensued was an almost comical culture clash, between the loud and cynical New Jersey natives and the more soft-spoken and mellow Indiana visitors.

Some issues were technical. None of the Indiana EMTs knew how to use stair chairs or lifts, which are critical for getting patients downstairs in the narrow rowhouses in North Bergen. A genuine observation: “It’s like they don’t have stairs there. Like maybe everything in Indiana is one story?”

When the New Jersey crew asked about the types of 911 calls they got in their area, the Indiana EMTs talked about “shooters” — people with guns shooting themselves or others by accident — a concept that left the urbanites agape. But it wasn’t long before the FEMA group earned their respect.

“They are totally not like us,” Prina said. “But they learned in 12 hours what took us months.”

With up to six ambulance trucks operating instead of three and the volume leveling off somewhat as it has in New York City these past few days, things have felt more in control, he said.

Yet the calls keep coming. A recent weekday morning brought some good news. A mother had called about her 20-something son, saying she couldn’t rouse him. The crew feared the worst, but when they arrived he was sitting up and chatting. Everyone smiled, but the reprieve was brief. The radio had started up again.

“She’s turning purple and fainted.”

“He’s blue and nonresponsive.”

“Reporting shortness of breath, back pain.”