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The Ripple Effects of a Travel Ban Could Make The Ebola Problem Even Worse

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Calls for an Ebola travel ban have gotten a lot louder. And they are not just coming from the lunatic fringe. Prominent Republican leaders, like House Speaker John Boehner, are now among those proposing to block travel from Guinea, Liberia, and Sierra Leone—the three countries where Ebola has already killed thousands.

Are these calls for closing the borders the product of political opportunism? Xenophobia? In some cases they are. But some of them represent good faith attempts to protect public health, both here and abroad. The editors of the National Review have endorsed a travel ban, for example. In their editorial, they went out of their way to stress the importance of helping the victims of Ebola in West Africa, by making exceptions for aid workers and such. But they’d stop others from going to those countries, and handle returning visitors on a case-by-case basis. 

These are not crazy arguments. But most public health experts remain opposed to such a sweeping travel ban, because they believe the potential downsides are a lot bigger than the potential upsides. These experts make some pretty compelling arguments of their own.

One is that a travel ban would affect the flow of personnel and supplies into the countries where the epidemic continues to spread. Experts, along with non-profits like Doctors Without Borders, say that they’d have a much harder time getting volunteers into the countries if those volunteers knew they could not easily return. Even with an explicit exception for aid workers, they say, the extra burden and uncertainty of having to get special clearance would dampen enthusiasm. Meanwhile, a U.S. travel ban would almost certainly cause other highly developed countries to follow, dramatically reducing the demand for flights and other transportation options to West Africa. Agencies already struggling to get supplies into the area would struggle even more.

Lots of people wonder, couldn’t the U.S. government just arrange other transportation—maybe a modern-day version of the 1948 Berlin airlift? I’ve put that question to a number of officials and experts and the answer I keep hearing is “no.” In the real world, they say, making these arrangements would be difficult and solutions would be inadequate. It’s not as if assistance is this highly organized campaign, with all the necessary aid workers and their supplies lined up at Dover Air Force base, just waiting for C-17s to take them across the Atlantic. The flow of people and wares into West Africa is a constantly changing, unpredictable blob that’s heavily dependent on freely available commercial transportation. Replacing that would take resources and time, the latter of which the region really doesn’t have.

Here’s Lawrence Gostin, director of the O’Neill Institute for National and Global Health Law at Georgetown University:

It isn’t remotely realistic that we could charter flights that were cost effective and would coordinate with all the relief efforts that are ongoing and will ramp up. And advocates for a ban are assuming it would only be the US and US aid workers. But the US launching a travel ban would cascade around the world virtually sealing a whole region off. Not only would aid workers be impeded but also essential medicines, food, and humanitarian supplies. Ultimately it would cripple those countries. 

A travel ban would also hurt the region economically. And while it might seem frivolous to worry about dollars (or other currencies) when it comes to matters of life and death, the issues are inextricably linked. The more the people of these countries face deprivation, whether its lack of jobs or lack of food, the more they will push to leave. It’s not at all far-fetched to imagine huge refugee flows out of these countries—the kind that even tight border controls couldn't fully stop. That would increase the chances that Ebola ends up in other African nations, including those with large urban centers and strong ties to global networks. Think of Ebola taking hold in the slums of Lagos or Nairobi, and how quickly it would jump from there to the rest of the continent and then beyond. It’s just one more example of how a travel ban, quite apart from its devastating effect on the region, could actually result in more cases eventually showing up on American shores.

“I just became persuaded after studying it ... that you’ll end up burning up a lot of resources and still get overtaken by the biological spread.” — Michael Leavitt, HHS Secretary under President Bush

Such an expansion of the epidemic would probably make the calls for a travel ban even louder. But the list of affected countries would grow quickly, and include international travel hubs throughout Asia and Europe. The ensuing complications are one reason that the Bush Administration, which did extensive research on travel restrictions during the avian flu outbreak, decided against a ban. Michael Leavitt, who as Secretary of Health and Human Services in the Bush Administration led the research effort, walked me through some of the logic.

It’s such an appealing idea, it sounds so easy. But it’s when you get to the second layer of activity and then the third and fourth it gets complicated. For example, imagine a Liberian citizen goes to Spain and in Spain he manifests symptoms and people in Spain get it. Do you now expand the travel ban to include Spain? Somebody from Spain goes to the U.K. and now it’s there, so do you include the U.K.? Now somebody who gets it there turns out to be a U.S. citizen and wants to come home to get treated. Do you let the citizen in?

Those complications alone wouldn’t have stopped the Bush Administration from imposing a ban. But officials also became convinced the ban just wouldn’t be very effective. People determined to evade travel restrictions, particularly family members, would find ways to do so. Models predicted that a ban might delay transmission to the U.S., not stop it altogether. Avian flu was airborne, so it's not quite the same situation. But models of Ebola's spread have come to similar conclusions. “I was honestly intrigued by the idea that, for periods of time, you could stop this,” Leavitt said. “I just became persuaded after studying it, and working through what you’d actually be undertaking, that you’ll end up burning up a lot of resources and still get overtaken by the biological spread anyway.”

There’s also a danger that restrictions would push transit into the shadows and underground, making it more difficult to keep track of who was where. “If [a ban] could be carried out, it might be effective in the narrow sense of preventing the entry of persons from those countries,” says Melinda Moore, a physician and public health expert who used to work at CDC and now focuses on these issues at the RAND Corporation. “But then again, it might drive people underground to game the system and circumvent ‘detection,’ to the detriment of everyone.”

Are these arguments ultimately persuasive? I think so, in part because I trust the medical experts who keep saying that the U.S. simply isn’t prone to a very large outbreak. It’s easy to forget, with the nonstop coverage on cable television, but only two people have contracted the disease here. Both were nurses exposed to a very sick patient at a time, and in an environment, when the public health system was seeing these cases for the first time. Everybody, from officials at the CDC to workers on the front lines, has learned from recent mistakes.

Most (though not all) experts I know agree. The data and research suggest that there are bound to be more cases here but there are not bound to be many more cases here—and that the top, overriding priority for U.S. policymakers should be doing everything possible to fight Ebola at the source, lest it spread and become a chronic, lingering menace to public health not just abroad but also here. Says Moore, “The best way to protect Americans, which is the objective of this potential policy, is to go all-out to curtail the epidemic in Africa while also ramping up hospital preparedness here in the USA.”

But reasonable people can hold different views and I, for one, would like to see officials think through a travel ban and how it might work in practice. One reason the proposal is tough to evaluate is that it’s not clear precisely what it would entail and what is actually possible. For example, could Customs and Border Patrol actually screen for and keep out all travelers to the region? Could the U.S. military create an ongoing airlift? If so, how quickly? As Moore explains,

Potential new policies, such as the proposed travel bans, should be examined from various perspectives before decisions are made.  What is the objective? How would it be carried out? How feasible is it? How timely could it be? How effective could it be in the best case scenario and how effective is it likely to be in practice? What are potential unintended negative consequences, and how likely are they?  How acceptable is the policy/intervention to those involved?  Are there alternative approaches that could achieve the same ends but with a better profile in terms of effectiveness, feasibility, acceptability, etc?

That last point, about "alternatives," is important. Officials should also think through restrictions that fall short of a ban. Visitors from the three affected countries are already subject to tougher airport screenings, with monitoring and even quarantines possible at the discretion of officials on the scene. Perhaps, as a rule, all visitors from West Africa should be subject to three weeks of monitoring and loose travel restrictions within the U.S. That approach would seem to have some appeal. It wouldn’t be the kind of deprivation or hardship that would discourage aid workers, or prod people into evading controls. But it would allow public health authorities to keep close tabs on anybody at even moderate risk of getting Ebola and, upon becoming symptomatic, transmitting it.

Such a solution would essentially treat visitors from the region the way we now treat health care workers who have come in contact with Ebola patients. It wouldn’t be perfect, but it might help without hurting, and perhaps ease public anxiety—which, in a situation like this, can be an important public health measure all on its own.