Travel Bans Will Increase the Damage Wrought by Ebola

No Evidence Travel Bans Work

The main reason that the leading public health agencies in the world—including the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC)—have opposed imposing travel bans is that there is no scientific or even good anecdotal evidence that bans have ever been effective at limiting the spread of contagious diseases.^2,3 A recent modeling analysis showed that the risk of international spread is related to the course of the epidemic in West Africa and that a travel ban, even if 80% effective, would only result in a delay of importation of cases of a few weeks. ⁴ An expert group convened by the WHO reviewed all of the available scientific evidence surrounding the use of travel bans and travel restrictions and determined that such measures were ineffective at limiting the spread of diseases like SARS and pandemic influenza. ⁵ HIV-related travel bans implemented by dozens of countries, including the United States, in the 1980s were not effective at slowing the spread of infection and led to “deleterious effects … at the societal level—negatively impacting HIV prevention and treatment efforts.” ^{6 (p1)}

The best hope of eliminating the Ebola threat to the United States is to stop the epidemic in West Africa. Travel bans would decrease the capacity of the US, other countries, and nongovernmental organizations to control this outbreak. The WHO has said that decreased flights to the region have already hindered the ability of response organizations to move staff and supplies in and out of the region. “Any discontinuation of transport will affect humanitarian aid, doctors, nurses and human resources entering the country, the transfer of biological sampling and equipment for hospitals. All of this needs international transporting, international airlines.…This will create more problems in helping the countries most affected,” said WHO Travel and Transport Task Force representative Daniel Menucci. ⁷ Doctors Without Borders, one of the leading nongovernmental organizations responding to Ebola in West Africa, said the scarcity of flights has already slowed relief efforts. ⁸ A senior director for the International Rescue Committee, which also has major Ebola-related programs in Liberia and Sierra Leone, has said that even discussions of a possible travel ban have made it more difficult for his organization to recruit new staff to go there because it raises concerns about their ability to get home. ⁹

Limiting the influx of supplies and personnel into Ebola-stricken countries would increase the likelihood that people will eventually seek to leave those countries in search of safety, health care, food, or shelter. This in turn would increase the likelihood of spread to other countries that may be ill equipped to handle Ebola cases. If Ebola were ever to take root in neighboring countries such as Nigeria or Mali, or in developing countries on other continents, that could drastically worsen the severity of the outbreak. The longer the outbreak rages on uncontrolled in Liberia, Sierra Leone, and Guinea, the higher the chance it will spread regionally and internationally, and the greater the prospect that it will become an endemic disease and move to other parts of Africa and the world—a real possibility that must be avoided with all possible efforts.

Intensified Economic and Humanitarian Toll

Cutting off Guinea, Sierra Leone, and Liberia from the rest of the world by denying US visas to citizens of these 3 countries, or by stopping or scaling back the number of commercial flights, would deepen the already devastating toll of Ebola there and set a dangerous precedent for the future. If the United States makes the decision to shut its borders and prohibit entry of citizens from those 3 countries, other countries are more likely to follow suit during this outbreak and future outbreaks. This could quickly lead to isolation of those countries. Commercial flights in and out of the affected countries have already been scaled back as many individual carriers have decided to suspend flights. While the US Department of Defense is working on setting up an “air bridge” in West Africa, the limited number of planes operated by the US military will not be able to deliver all the medical supplies, personnel, food, fuel, and other provisions that the 22 million people in these 3 countries will need to survive for the duration of the outbreak. ¹⁰

Stopping travel in the region would undermine the economies of the 3 affected African countries. The World Bank estimated Ebola is likely to cause a $3.8 billion loss in gross domestic product in these countries by the end of 2015. ¹¹ Fears about Ebola have already diminished trade in those countries, leading to widespread shortages of critical supplies like food and fuel. ⁵ Further restricting the movement of goods and people out of the 3 countries will exacerbate these losses and the level of economic and humanitarian disaster that is occurring.

Reducing travel to and from the region also threatens the US economic stake there. There is substantial annual trade between the United States and Guinea, Sierra Leone, and Liberia. At least one large US company, Firestone, has a dedicated presence in the region and has been successful in controlling the spread of Ebola among its employees. ¹² Cutting off travel and trade with West Africa would threaten investments the United States has already made to bring political stability to the region, including the hundreds of millions of dollars in foreign assistance the US has spent annually to help Liberia transition to peace after civil war.

Contrary to International Agreements

Countries that decide to implement travel bans for this Ebola outbreak do so without the backing of international law. The core goal of the International Health Regulations (IHRs)—the legal framework that articulates how nations, including the United States, should respond to international disease threats—is to “prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.” ¹³ The IHRs actively discourage the use of measures for which scientific evidence is lacking. Since the WHO strongly urged countries not to ban or limit flights from West Africa, countries that take these measures are interfering with international travel and trade—actions IHR agreements are meant to protect against.

Restrictive travel and trade actions have worsened the social and economic tolls of past outbreaks. During the 2009 H1N1 influenza pandemic, a number of countries restricted flights to or from North America and quarantined passengers from the area. In spite of a joint statement by the WHO, the United Nations Food and Agriculture Organization (FAO), the World Organization for Animal Health (OIE), and the World Trade Organization (WTO) that stated that pork and pork products could not transmit H1N1 influenza, more than 20 countries implemented full or partial bans on US pork imports and caused more $1 billion in losses to the industry.^14,15 The United States would be in a better position in future outbreaks if we resist pressures to implement travel bans in this current crisis and argue against countries taking such measures that will ultimately hurt African, US, and the global economy.

Effective Planning to Prevent Outbreaks

In addition to intensifying contributions to control Ebola in West Africa, there are a series of effective actions the United States is taking to decrease the chance that Ebola will spread in the US. Exit screening from affected countries has some value in identifying people at high risk of Ebola. ² Informing travelers arriving in the United States about the symptoms of Ebola and what to do if they experience symptoms is of clear benefit. We have learned from past outbreaks like SARS that passive surveillance methods (in which symptomatic individuals report illness) can be more effective than travel screening or bans. ¹⁶ Travelers to the United States from any country that has Ebola cases now receive information that details the symptoms and risk factors for Ebola and what to do if they develop them post-arrival. This information explains in clear terms the symptoms of Ebola, who is most at risk for infection, who to call to report an at-risk individual who is experiencing symptoms consistent with Ebola, and how symptomatic individuals can safely isolate themselves while they await medical help in order to prevent transmission. Under newly issued guidelines, the CDC now recommends that all travelers arriving in the United States from affected countries check their own symptoms twice daily and report the results to local health departments. In addition, the CDC guidance stratifies travelers based on risk of exposure to Ebola and recommends additional monitoring and restriction of movement for those at higher risk. ¹⁷ For example, the CDC recommends that individuals in the highest risk category (eg, healthcare workers who had unprotected exposure to the infectious bodily fluids of Ebola patients) be actively monitored for Ebola symptoms by health departments and avoid mass gatherings and transit.

We need to continue to strengthen efforts to screen symptomatic patients at the nation's hospitals and healthcare facilities, where any final diagnosis of Ebola will eventually be made and where treatment will occur. The successful treatment of 2 Dallas nurses, an NBC journalist, and several aid workers has shown that safe and effective care for Ebola patients is possible in US hospitals that have the necessary systems and training in place. We need to ensure that doctors and nurses, who will be the first point of contact with potential Ebola patients, know the signs and symptoms of Ebola, ask about risk factors for infection, isolate suspect cases, and appropriately use personal protective equipment.