Fear, Quarantine, and the Politics of Disease

Photo Credit: Frances Kennedy, WFP

Editor’s note: Matthew Ware is a second-year student at Yale-NUS College. He is studying Global Affairs with a focus on Public Health.

From Ebola to Zika, politicians around the world have called for and implemented quarantines to control infectious diseases despite the fact that the WHO and CDC both oppose this. If taken up on a broader scale, these domestically popular measures might be disastrous for global health in a future epidemic.

Global epidemic diseases like H1N1, Zika, and Ebola have a unique capacity to inspire fear. They conjure vague allusions to violence and invasion in the public imaginary – from news reports that show maps of the countries where the infection is being transmitted and arrows reminiscent of troop movements pointing at where it might reach next, to medical literature and government reports, which continue to use terms with juridical and military undertones, like “defaulter”, “control” and “suspect.”

At the intersection of illness and politics lie myriad opportunities to address these fears, or alternatively, capitalize upon them. The emotive capacity of disease was not lost on US campaign strategists, who thought up advertisements like this one in 2014, entitled “Trust”, suggesting voters should be wary of “terrorism and Ebola, coming at us from overseas.” The candidate, a relatively unknown political figure from Georgia named David Perdue, is now a US Senator. But beyond the mere evocation of infectious disease to win elections, there is something far more concerning.

During the 2014 Ebola virus disease epidemic in West Africa, South Africa banned travelers from the affected countries from entering its territory. Caribbean nations Jamaica and Guyana followed suit, and the Kenyan health ministry called for a temporary ban. Canada and Australia stopped issuing visas to nationals of Sierra Leone, Guinea and Nigeria. Airlines faced pressure to cancel flights, with British Airways, Emirates Airline and Kenya Airways suspending their routes. At one point, Brussels Airlines was the only non-African airline flying to all three countries with large numbers of Ebola patients, and it faced significant political pressure to halt that service. The US state of New Jersey put in place mandatory quarantines for all health workers returning from West Africa, which affected one of New York’s major transit hubs, Newark-Liberty Airport. That state’s governor, Mr Chris Christie, has suggested he will do the same for Zika virus.

All of these measures are good politicsthey will be perennially popular amongst constituents and employees; they score points with voters in primary election debates, and appease flight crews who feel uncomfortable boarding planes to places like Conakry and Freetown. The politicians putting them in place can pat each other on the back for having done something. And they pass comedian Stephen Colbert’s “truthiness” test. That is to say, they sound right. In the language of the public imaginary, if disease seems to be something like a foreign invasion, drastic measures must be necessary to stop it. We imagine a public health response that looks something like Outbreak or The Andromeda Strain, not the messy details of contact tracing or the banality of symptom checks.

What is alarming about these measures of ‘public health theatre’ is that they were all put in place unilaterally, by national-level politicians or corporate executives, against the advice of the World Health Organisation, the US Centers for Disease Control and Prevention (CDC), and international NGOs like Médecins Sans Frontières (MSF). They are a failure of the very global governance processes which are supposed to help the world deal with these types of crises. There is a very strong scientific consensus — which important state and corporate actors in the international system ignored – that restrictive policies like quarantines, flight cancellations and travel bans don’t serve their intended purpose, and actually create substantial risks which could endanger public health further.

Arrival quarantines mainly affect health workers and international aid volunteers, discouraging them from travelling abroad.Following the New Jersey quarantine put in place by Governor Chris Christie, and a similar measure in New York, applications from US citizens to serve in the affected countries declined by 17%. MSF Press Officer Tim Shenk told a New Jersey paper that “For U.S. staff, especially as state [quarantine] policies changed, some people shortened their assignments due to the restrictions they face when they return home.” This came at a time when MSF was so understaffed that at some Ebola Treatment Centres, it was only providing basic palliative care to the patients. Often, MSF treatment centres were not even able to use intravenous fluids, which can make a huge difference in treating dehydration, but require staff to monitor.

The harms caused by travel bans and flight cancellations are more difficult to quantify, but they are well understood. At best, they delay, and do not halt, transmission of an infectious disease by at least 10 and 30 days, depending on the proximity of the regions. In exchange for that meagre purchase of time, they make disease surveillance much more difficult, disrupting historical travel patterns as well as electronic and paper trails. For example, a passenger boarding a flight in Lagos would have his or her temperature taken, and then upon arrival in, say, New York, could receive a follow-up screening and instructions on how to report symptoms. (This is what the US Centres for Disease Control and Prevention actually did during the Ebola crisis.) However, if that passenger is banned from taking the direct flight to New York, or the flight is suspended, he or she may cross land borders, avoiding document checks and health screeningsreasonably common, in some regions of the worldto travel from alternate airports that do not check for Ebola symptoms; or use false documents and avoid the system entirely. One of the biggest problems in contact tracing, a system which attempts to follow-up with people who may have been exposed to an infected person, is the fact that some segments of a population may be wary or distrustful of health workers. In these situations, the patience, empathy and compassion an aid volunteer can offer may literally be a matter of life and death. Travel bans and arbitrary, unscientific cancellations of air routes promise to wipe away the efforts of contact tracing, if they force people to cross borders without documentation or symptom checks, by effectively “losing” any infected persons who may choose to travel out of the region.

Even in the case of Zika virus, which is transmitted primarily by mosquitoes, quarantines and travel bans have the potential to disrupt economies and separate families – all for zero public health benefit, because they don’t work in the first place. They increase the likelihood people will avoid traditional travel patterns, skip medical surveillance measures, or distrust government officials who suggest control and restrictions are the answer – decades of international experience, the world’s preeminent health agencies and sound research be damned.

In a world where transportation is faster and easier to access by more people than ever before, disease can travel as quickly as commerce. But when epidemic diseases appear on the horizon, we cannot let our response be dictated by fear, or the misguided ideas of bombastic politicians, or a vague idea of what “feels right”. Because we don’t live in the world of Outbreak. instead, ours is one where reason, data and compassion make all the difference.