Early last week, about as soon as the Centers for Disease Control and Prevention said that it had learned that a man in Texas had been infected with the Ebola virus after having travelled in Liberia, people started suggesting that maybe the U.S. should ban people from flying here from West Africa.
Atul Gawande wrote on Friday about the failure of communication at Texas Health Presbyterian, the hospital that treated the patient but discharged him, at first, with a diagnosis of gastroenteritis; he also outlined the well-established procedures that hospitals and public-health workers should use to contain an outbreak. But how can the U.S. keep infected people from arriving in here in the first place?
In this case, it’s hard to see how it could have been prevented. While in Liberia, the man had helped to carry a pregnant woman who was infected with Ebola to a taxi. But when he arrived at the airport in Monrovia, he didn’t have Ebola symptoms—which staffers had been trained to look for—and, when he filled out an airport-screening form, he answered no to questions about whether he had cared for an Ebola patient or touched the body of someone who had died in an area affected by Ebola. (Liberian authorities said that they would prosecute the man, who is Liberian, for lying on the form, but it’s unclear whether he knew the woman had Ebola; the Associated Press reported that “her illness at the time was believed to be pregnancy-related.”)
Those living and working in Ebola-stricken areas have grown to be well aware that it’s difficult to detect infection early on. But some in the U.S. were surprised—and concerned—when they considered the implications for travel: if it’s so difficult to know for sure whether someone has been infected with Ebola, some have argued, shouldn’t the U.S. be able to stop people who have been exposed to Ebola from arriving here on commercial flights? To be safe, what about blocking everyone who has spent time in Liberia, Sierra Leone, and Guinea?
Those who have questioned whether the existing controls are strong enough, such as Senator Ted Cruz, the Republican from Texas, have pointed out that several African countries have restricted or shut down air travel to countries with confirmed Ebola cases. Maybe the U.S. should simply stop airlines from traveling to those countries.
The fact is, U.S. airlines don’t fly to the countries with ongoing Ebola outbreaks. Delta used to fly to Monrovia, but stopped in August. Today, only Delta and United offer direct, nonstop service between the U.S. and West Africa, according to Airlines for America, a trade group for U.S. airlines—Delta to Lagos, Accra, and Dakar, and United to Lagos alone. The Ebola patient in Texas first flew from Monrovia to Brussels on a different airline, reportedly Brussels Airlines, then boarded a United flight to Washington, D.C., and another one to Dallas.
Airlines could suspend flights to the West African countries where they do fly, if they choose, but that wouldn’t necessarily keep passengers from Ebola-stricken countries from using other airlines to leave Liberia and later boarding their flights, as the Texas man did. To keep people who have been in West Africa from boarding U.S. carriers would be more difficult; typically, screenings are left to airport and public-health workers, with airlines getting involved only if a passenger is obviously ill and is seen as presenting a danger to crew members or other passengers.
So far, airlines are relying on the C.D.C. and the World Health Organization for guidance on how to respond. Jennifer Dohm, a United spokeswoman, told me in an e-mail, “We have not made any flight changes at this time, but are in regular communication with government agencies and health officials and will follow their recommendations that apply to our operation.” Health officials, in turn, have not recommended travel bans; in fact, the World Health Organization recommends the opposite— “no bans on international travel or trade.”
There are several reasons for this. For one thing, as Gawande points out, travel bans don’t really work: “Even if travel could be reduced by eighty per cent—itself a feat—models predict that new transmissions would be delayed only a few weeks.” For another, they make it even more difficult to address the public-health crisis: “If you try to shut down air travel and sea travel, you risk affecting to a huge extent the economy, people’s livelihoods, and their ability to get around without stopping the virus from traveling,” Gregory Hartl, a W.H.O. spokesman, said, according to the Washington Post. “You can’t ship goods in. Sometimes these goods are basic staples people need to survive.”
Some have protested that the U.S. and its airlines still ought to close themselves off from people travelling from Liberia, Sierra Leone, and Guinea to protect American citizens, whatever the potential enforcement difficulties or the harm to those abroad—if not by banning travel from certain countries altogether then by banning certain passengers from getting on planes. On the Web site of the National Review, Mark Krikorian wrote, “You can hear the objections now: It would be xenophobic, it might stigmatize West Africans, those countries will object to our State Department that they’re being discriminated against.”
These objections, it should be noted, are legitimate. But, on Thursday, Tom Frieden, the director of the C.D.C., offered another line of reasoning. Robert Ray of Al Jazeera America asked him whether the U.S. could require more rigorous screenings, in the U.S., of passengers arriving from West Africa. “Do you think that there should be something put in place for international travelers, specifically people coming in from West Africa, when they land here in the U.S. that perhaps their fever—their temperature should be taken right away because what if, what if, like I said, some desperate person over there knows that they have been exposed and they can afford a plane ticket and they know if they land here in the U.S., they can get that proper care, no matter what?” Ray asked.
In response, Frieden explained that such measures would make it harder to send aid workers into those places because of the difficulty of bringing them home afterward. “They're not going to be able to come out if they go in,” he said. “And because of that, it will enable the disease to spread more widely there and ultimately potentially spread more to other countries in Africa and become more of a risk to us here, so that the best way to protect ourselves is not to try to seal off these countries but to provide the kind of services that are needed so that the disease is contained there and to identify anyone who may come out.” There may be situations in which the U.S. could benefit from keeping out of other countries’ affairs; this, public-health officials seem to agree, is not one of them.