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Ebola: Choosing Wisdom Over Worry

There are, of course, countless options between having no policy at all and implementing drastic quarantine and travel ban policies. Hopefully, we as Americans can reflect upon our past behaviors with epidemics in order to implement the most careful, courageous, and helpful responses to this international threat.
10/28/2014 09:51am ET | Updated December 28, 2014
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Tourists queue up at Suvarnbhumi Airport to give their health record before leaving the airport in Bangkok Thailand Monday, Oct . 27, 2014. The longer the Ebola outbreak rages in West Africa, the greater chance a traveler infected with the virus touches down in an Asian city.(AP Photo/Sakchai Lalit)

Epidemics arouse tremendous fear and elicit a host of common responses, despite very different contexts. This fall, Americans have grappled with the news that Ebola is on American soil: One person has died from it, two others are recovering from it, a physician in New York City now appears to have contracted it while caring for patients in West Africa, governors in some states are quarantining providers traveling from affected countries, and many Americans presently live in fear that they have been exposed to it. The news has caused many Americans to panic at the news, and they are demanding that government and public health officials do everything to keep Ebola away from the U.S. and to keep them safe in this epidemic.

The symptoms of epidemic diseases can often be grim, prompting alarm in the public imagination and compelling authorities to respond in extreme ways. Take yellow fever or cholera, diseases that ravaged North America at various times in our past. In roughly 15 percent of yellow fever cases, individuals developed a severe form of the disease that included high fever, jaundice, bleeding, and eventually multi-organ failure. Likewise, in approximately 5-10 percent of cholera cases, people develop profuse diarrhea, low blood pressure, muscle cramps, and eventually severe dehydration, acute renal failure, coma, shock, and death. Fears about these and other horrible diseases generated extreme discrimination against immigrants and other vulnerable populations. Fears also prompted regional authorities and eventually the federal government in the U.S. to establish, among other things, a national quarantine system and public health standards.

Ebola today conjures similarly horrific images, both because of its graphic symptoms (high fever, stomach pain, diarrhea, vomiting, and unexplained bleeding) and its high death rates (this epidemic's fatality rate is around 70 percent, but rates have ranged between 25 percent and 90 percent in past outbreaks). It is understandable that public figures have called for policy solutions to protect Americans. Some policy solutions have come quickly and loudly and seem to ring of common sense. On Oct. 2, for example, U.S. Senator Ted Cruz (R-TX) called on the FAA to take every available precaution in preventing additional cases from arriving in the United States." Among the precautions Cruz listed "restricted or banned air travel to countries with confirmed cases of the Ebola virus" and "suspended flights" due to the rising death toll and deteriorating public health situation in Ebola-stricken countries. On Oct. 8, a group of 27 lawmakers in the U.S., including three Democrats, urged the Obama administration to halt flights from the affected countries. At a congressional hearing last week, U.S. Representative Tim Murphy (R-PA) called for "an immediate ban on non-essential commercial travel from Guinea, Liberia, and Sierra Leone." These appeals have grown in recent days, and even politicians who formerly opposed an Ebola travel ban have now bowed to public and political pressure and backtracked. Others, such as celebrity businessman Donald Trump, have offered similar proposals in much less diplomatic fashion.

Other public figures, however, have been more circumspect about travel bans as a policy option. Before he changed his position, Texas Governor Rick Perry argued that flight bans would be an inefficient way to control Ebola's spread. California Representative Henry Waxman, at the recent congressional hearing on Ebola, argued that "sealing people off in Africa is not going to keep them from traveling, they'll travel to Brussels ... and then into the United States. We can stop the epidemic from spreading if we isolate the patient and ... monitor the contacts of that patient. If we do that we can stop it there and we can stop it here." These arguments comport with what Americans have heard from the U.S. Centers for Disease Control and Prevention (CDC) and the National Institute of Allergy and Infectious Diseases (NIAID). Tom Frieden, director of the CDC, maintains that a travel ban would isolate infected countries, sending travelers to adjacent nations to find transportation, effectively spreading the epidemic in Africa and potentially raising the risk for other continents. Likewise Tony Fauci, head of the NIAID, argues that a travel ban would not stop potentially infected people from coming to the U.S. but would prevent health and transportation officials from being able to track them. Leading public health and infectious disease professionals have largely echoed these points.

Travel bans are of course not new either to the U.S. or to the global fight against infectious diseases. Perhaps the most prominent set of travel bans in response to a global epidemic in modern times came during the first decade of the AIDS pandemic. As early as 1986, several countries including the U.S. began screening or banning foreigners or people with HIV from entering their borders. The problem with travel bans then, as now, was that they weren't an effective way to combat the disease in question. In the fight against AIDS, experts like the WHO's Jonathan Mann argued that travel bans were more about political posturing than public health. "For countries ... to consider screening selectively people from different parts of the world in order to try to protect their own home populations from infection does not make any sense, and WHO is strongly opposed to it," Mann told reporters in 1986 (Prentice, 1986; See also Fee and Perry, 2008). By 1989, as Vox Media has noted, evidence suggested these travel bans had little positive effect. They did divert funds from other effective interventions, however.

WHO and UNAIDS still oppose HIV travel bans (and, thankfully, U.S. President Barak Obama finally ended the U.S. HIV travel ban four years ago), and WHO has recently gone on record opposing Ebola travel bans as well. Travel bans and even screening are largely ineffective, and they divert resources from the more crucial effort to trace contacts and stifle the virus' spread. Evidence from H1N1 epidemic indicates that targeted interventions and effective care, treatment, and prevention in affected countries, rather than travel bans, has best decreased the risk of transmission. Recent computer models suggest travel bans would only temporarily delay, but not materially affect, the trajectory and spread of the epidemic.

Mann argued then with HIV, and the principle still applies today with Ebola, that countries should vigorously fight epidemics. No one in the U.S. government desires anything less, despite what various radio commentators might suggest. However, the U.S. and other nations should combat Ebola in ways that contain Ebola successfully, rather than by embracing ineffectual health policies and discriminatory approaches. Some political posturing to calm people will no doubt ensue, which explains why the CDC has adopted their most recent approach to traveler screening (where passengers are screened upon exiting the affected counties and then re-screened and tracked in an enhanced way when they arrive at the five airports that receive most travelers from the affected countries). While these expensive actions will probably identify few people with Ebola, they will build confidence with the public and prevent us from adopting even more costly, more futile actions in the fight against Ebola. Some posturing will go too far, however, which is why the CDC opposes the actions taken by these governors to impose quarantines on health care providers returning from affected countries. Those actions, infectious disease specialists have argued, are overblown, unnecessary, and punitive; some observers have suggested they are possibly illegal. There are, of course, countless options between having no policy at all and implementing drastic quarantine and travel ban policies. Hopefully, we as Americans can reflect upon our past behaviors with epidemics -- the good and the bad -- in order to implement the most careful, courageous, and helpful responses to this international threat.