In the wake of last week’s confirmation of the first domestic case of Ebola in the United States, more than a few people have suggested that the only way to stop the virus from reaching American soil again is to ban flights from West Africa.
Leading Republicans this week rushed to opine on the issue, calling for stringent new restrictions on air travel to and from Ebola-affected countries. Among those calling for travel bans was Sen. Ted Cruz (R), who wrote a letter to the Federal Aviation Administration pointing out that the busy holiday season is looming and asked if the agency is planning on limiting or suspending air travel to the countries where Ebola is prevalent. Meanwhile, Texas Representative Ted Poe, a Republican, has written to the Centers for Disease Control asking it to recommend travel restrictions, while Governor Bobby Jindal has called for a ban on air travel to the U.S. from the countries where the epidemic is present.
And in an editorial published on Sunday, Forbes contributor Steven Salzberg seconded Gov. Jindal’s call for a complete travel ban, saying that the “only” way to protect the U.S. from an Ebola outbreak is to stop travel to and from Liberia, Guinea, and Sierra Leone. “I’m not arguing that we should ‘seal ourselves off from the world,’” wrote Salzberg. “We are arguing to seal off just three small countries in West Africa, until the epidemic passes.”
The White House is resisting those calls, as they should be. Restricting travel to and from the affected region will have little impact on the already minimal risk to Americans from the Ebola virus, while further worsening an already desperate situation in West Africa. Public health officials have pushed back against such a move, saying that it would result in economic damage and keep doctors, nurses, humanitarian workers and needed supplies from reaching the region. And the history of the global fight against infectious disease has demonstrated that we shouldn’t run away or attempt to throw up barricades, but fight disease wherever we find it.
As Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention, said last week, “The plain truth is, we can’t make the risk zero until the outbreak is controlled in West Africa. What we can do is minimize that risk.”
Travel bans should remain a relic of the past
Travel restrictions have been used throughout history as a tool against the spread of disease. Quarantine was first used against the plague in 14th-century Europe. However, the case for plague quarantine was a lot stronger 600 years ago: It was pretty much the only potentially effective public health strategy at the time (as prayer had failed to produce the desired results). The Yersinia pestis bacteria that caused the Black Death still exists — there were four cases of human infection in the U.S. in 2012 — but we now have a vaccine to prevent the disease and effective drugs (antibiotics) to treat it. Sanitary and housing conditions in the 21st century are incomparable to those in Europe in the 1300s, when raw sewage ran down the streets straight into the reservoirs used for drinking water. The plague led to the deaths of tens of millions in the 14th century; today, it kills a few hundred people worldwide each year.
Though Ebola is a scary virus, it’s not nearly as contagious as other infectious diseases like the flu.
There is no vaccine against Ebola, nor a fully developed cure. But, like the plague in modern times, Ebola is unlikely to reach epidemic status in the U.S. or elsewhere in the developed world. Ebola is not easily transmissible: it spreads only through direct soft tissue contact (e.g., eyes, mouth) with the bodily fluids of someone with active symptoms of the virus. Protective gear works, if you know how to use it and, of course, if you can get your hands on it. That’s the problem in West Africa, where thousands have already died. The health care infrastructure is weak, while supplies and trained professionals are in short supply.
In Sierra Leone, where an estimated 765 new Ebola cases were recorded just last week, there are fewer than 330 beds available to treat patients with the virus. In neighboring Liberia, frightened health care workers – most of whom don’t have access to proper gear to protect themselves – are fleeing the communities in which they work, leaving their already overworked colleagues to shoulder the excess burden. According to a new report released Tuesday (Oct. 8) by the CDC and their Liberian colleagues, only three physicians remain in all of Liberia. Health care workers have also repeatedly come under attack by suspicious community members, which has severely hampered efforts to identify and track down Ebola patients and their family members.
But that’s a far cry from the U.S., where the public health infrastructure is well established and health authorities are experienced in the process of “contact tracing”, or identifying anyone with whom the victim has had contact since they began exhibiting symptoms and checking that they don’t have the disease. Even though staff at a Dallas hospital failed to recognize that Ebola patient Thomas Duncan had the virus when he first showed up in their emergency room, officials with the CDC say they’ve now tracked down and are monitoring everybody who came into contact with him. All of which explains why Dr. Frieden has expressed confidence that Ebola will be stopped in its tracks in America.
Counterproductive effects of banning flights
Controlling illness by quarantine of an entire country or region is also implausible – the idea that we could completely seal off the U.S. from the rest of the world is laughable. This is because of the simple realities of the disease ravaging West Africa, whose symptoms take time to manifest, as well as the nature of air travel in the 21st century. At best, we might delay a disease from reaching the country by a few days or weeks. But we can’t stay isolated forever, and the Ebola virus makes frequent jumps into the human population; eventually, it would make its way onto American soil. If not Ebola, then another contagion. With new infectious diseases emerging at a faster pace now than ever before, escaping their reach is simply not possible; rather, we need to prepare for their arrival.
Public health officials are realistic about this point, openly stating that the danger of additional Ebola cases in the United States will remain real as long as the outbreak is raging in West Africa, where the disease has killed more than 3,400 people and infected nearly double that many. “Although we might wish we could seal ourselves off from the world, there are Americans who have the right of return; there are many other people who have the right to enter this county,” Dr. Frieden said last week. “We’re not going be able to get to zero risks, no matter what we do, unless and until we control the outbreak in West Africa.”
Experts agree that restricting travel to and from affected countries in West Africa would worsen the outbreak by obstructing the delivery of crucial resources, including health care professionals and protective equipment.
Stopping the outbreak will require a tremendous global effort, which is exactly why leading health officials say travel bans would actually be counterproductive. The three West African countries affected desperately need outside support, including the hundreds of medical volunteers who have stepped forward from countries as disparate as Cuba and the U.K. Ban flights into West Africa, and you will delay help arriving when every day is critical in preventing an explosion of cases. Ban flights out of the countries, and you will deter people from volunteering to work in the region.
As Dr. Frieden explained, implementing a travel ban could make the outbreak even more dangerous.”Paradoxically, something that we did to try to protect ourselves might actually increase our risk,” he said. Dr. Frieden noted as an example that on his recent trip to Liberia, hundreds of health workers en route to the Ebola-ravaged country had gotten stuck in neighboring Senegal. “Senegal had taken that action in order to protect themselves, stopping all flights, but that action ended up making it harder to stop the outbreak in Liberia and elsewhere and potentially increased the risk to that country,” he said.
“[Travel bans] impede and slow down the ability of the United States and other international partners to actually get expertise and capabilities and equipment into the affected areas,” Lisa Monaco, assistant to the president for Homeland Security, said at a White House briefing on Oct. 3. Monaco reiterated the point that the most effective strategy to thwart the spread of Ebola “is to control the epidemic at its source” by getting assistance into the impacted countries to ratchet down the disease.
Expanding on that point in a recent essay for the New Yorker, Dr. Atul Gawande, a physician, explains why a travel ban would be so counter-productive:
No travel ban or quarantine will seal a country completely. Even if travel could be reduced by eighty percent—itself a feat—models predict that new transmissions would be delayed only a few weeks. Worse, it would only drive an increase in the number of cases at the source. Health-care workers who have fallen ill would not be able to get out for treatment, and the international health personnel needed to quell the outbreak would no longer be able to go in. The local economy and health infrastructure would further collapse, causing a far wider spread of the disease. For months, Doctors Without Borders—almost the lone group providing treatment services—has been crying out for help. The international response was contemptible.
Emerging diseases in an interconnected world
Even without a formal travel ban, reduced commerce associated with disease outbreaks can cause major economic damage, particularly in countries with developing economies. A 2006 World Bank staff estimate of the global costs of a flu pandemic suggested it could reduce global GDP by $1.5 trillion. One-third of that sum was accounted for by death, illness, and absenteeism. But two-thirds was due to the cost of efforts, including reduced travel, to keep away from infection. The World Bank has estimated the cost to Liberia of the Ebola outbreak in 2014 to be equal to more than 3 percent of the country’s GDP. Add in a formal travel ban, and the impact on some of the world’s poorest economies could be catastrophic.
But with greater support, the three countries bearing the brunt of the epidemic can fight back against Ebola. Neighboring Nigeria and Senegal have shown that Ebola can be detected, victims isolated, their contacts traced, and the disease shut down. And while Liberia, Guinea, and Sierra Leone have desperately fragile and underfunded health systems made worse by Ebola’s toll on medical staff, their programs aren’t completely dysfunctional. All three countries have completely wiped out major infections: smallpox, polio, and guinea worm. Liberia and Sierra Leone regularly vaccinate 9 out of 10 children against diphtheria, whooping cough, and tetanus, while Guinea vaccinates nearly two-thirds of children against the three diseases.
In today’s interconnected world, banning air travel will only delay, but not stop, the arrival of new diseases. The better solution, experts say, is to fight the disease where it emerged.
The lesson of the world’s efforts to stop other deadly diseases is that if we want to reduce our exposure to dangerous pathogens, we have to fight them where they are and when they emerge. We’ve seen incredible progress against a range of infectious diseases over the past 20 years because of the rollout of vaccinations and other interventions in even the poorest countries: From 1990 to 2010, according to the Global Burden of Disease Study, the number of tuberculosis deaths worldwide each year dropped by 276,000. Deaths from cholera and whooping cough each more than halved, saving more than 120,000 lives a year. And the number of deaths each year from tetanus and measles combined tumbled from 900,000 to 187,000. Just these five diseases kill more than 1 million fewer people each year than they did 20 years ago.
This global progress is the most powerful weapon we have in permanently reducing the risk and cost of infectious disease in the U.S. The eradication of smallpox has saved somewhere more than 40 million lives, but it also saves about $2 billion a year in vaccination and hospital expenditures in the U.S. alone—an impressive return for a global program that cost about $300 million.
Continued global progress against infection involves more financing for institutions that support the fight against contagion worldwide, such as PEPFAR and the Global Alliance for Vaccines and Immunizations. And, critically, it also means providing financial, human, and moral support for national health systems worldwide to ensure they can better respond to outbreaks. And that’s impossible if we simply close our doors and cut the people of West Africa off from the rest of the world.
We live in a global disease pool. In the end, once a disease begins to spread, there’s no escaping an infection, whether it first appears in Africa, Asia, or the U.S. Travel bans are less effective than hiding under a rock and considerably more costly. To battle continuing epidemics and any future potential pandemics, we need strong health and surveillance systems in every country and research and development not just for the diseases of the rich but for the infections of the poor. Hitting emerging disease threats early and where they emerge is far less costly in terms of lives and financing than trying to play catch-up once they have spread.