The isolated cases of Ebola that emerged recently in Dallas and New York City have sent ripples of fear across North America. We should not be surprised. Ebola is a scary disease, in which typically half of those infected with the virus will die. Close to 5,000 people have succumbed already, according to the World Health Organization (WHO), which has warned that the number of new cases in West Africa where the current outbreak originated may accelerate to 10,000 per week by December. There remains a great deal that health authorities don’t know about Ebola, and this uncertainty stokes public fear.
In this panicky environment, politicians and public health officials are under pressure to take bold steps to protect against the threat – though such measures may not be warranted or even do more harm. There is controversy, for example, over the decision by some US public health authorities to quarantine individuals who may have been exposed to the disease but show no signs of having contracted it.
Perhaps more significantly, there is increasing public and media pressure on governments to ban travel to and from the worst Ebola-affected countries. Last week, Australia became the first developed country to shut its borders to visitors from Sierra Leone, Guinea and Liberia. Canada has also recently announced it will not issue visas to countries with widespread Ebola.
While on the surface travel restrictions may appear to be a reasonable response to a crisis like Ebola, they can have important consequences. Imposing what amounts to a quarantine on entire countries or regions could have a serious impact on the world’s ability to contain pandemics – not just in the case of Ebola, but in future outbreaks as well.
Travel bans are potentially problematic for several reasons. First and foremost, these bans can have adversely affected the target country’s economy. In the early 2000s, the combination of the SARS (severe acute respiratory syndrome) outbreak and the WHO’s cautionary travel advisory cost the economy of Toronto approximately one billion dollars. This potential economic consequence creates a powerful incentive for affected countries to not report or delay reporting outbreaks, with the result that affected countries may not receive the assistance they need to control the outbreak in its earliest stages. Because of the exponential growth in number of infected individuals, the best time to intervene to prevent the further spread of outbreaks is at its outset. Mitigation strategies such as the distribution of anti-virals or antibiotics, social distancing measures or vaccination, however, may require resources that may not be forthcoming if countries do not report. Failure to disclose will also result in other countries not being able to prepare and introduce screening measures to prevent the spread of the disease across their borders.
The problem of hiding outbreaks is not new. During bubonic plague outbreaks centuries ago, countries would resist reporting because of the fear of the economic consequences that resulted from quarantine measures. Nineteenth century economies were adversely affected by travel and trade restrictions due to cholera outbreaks. In the aftermath of the 2002 SARS pandemic and in anticipation of a global flu pandemic, new rules were created to provide guidance on what measures should be introduced to protect against the international spread of public health emergencies. The revised International Health Regulations represented a revolutionary change in international law where member states essentially ceded this authority to the WHO.
The regulations work as follows: Countries commit to conduct surveillance to identify potential public health emergencies, (not limited to infectious disease outbreaks) that are a risk to spread internationally. They are required to assess and rapidly report any unusual events within their borders to the WHO. In turn, the WHO will provide assistance to the reporting country to manage the emergency, will alert other countries and provide recommendations to prevent the international spread of the disease – while minimally interfering with international travel and trade.
Utilizing the regulations, the WHO moved early to declare Ebola a public health emergency of international concern. This declaration was accompanied by recommendations to prevent the further spread of the disease. However, the WHO also specifically stated that there should be no general travel ban to affected regions. Nevertheless, some countries have exceeded these recommendations. Australia’s visa restrictions have been condemned by not only the targeted countries but by public health officials and UN secretary-general Ban Ki-Moon.
Having no enforcement mechanism, the system of disease control embodied by the regulations is therefore largely based on trust. Countries must have confidence in the WHO’s judgment on what constitutes a public health emergency and what measures are appropriate. The recent revelations that the WHO may not have had the best information on Ebola and admitted to mishandling the response are thus particularly concerning as we move forward.
If a crisis of confidence in WHO leadership emerges in the aftermath of Ebola, countries may not adhere to WHO advice in the future. They may act independently by prematurely closing borders when becoming aware of an external threat. This will create an incentive for affected countries to not report outbreaks, with the knock-on effect that these countries will not get the assistance they need to aggressively tackle diseases at their outset. In combination with other countries not being aware of the threat, such a scenario makes it even more likely that outbreaks will spread.
How then best to prevent this from happening? A review of Ebola and the effectiveness of the regulations to control its spread will be critical. The following questions will need to be answered: Was disease surveillance at the ground level adequate? Was accurate information reported to the WHO in a timely manner? Was WHO guidance correct?
Those technical questions go to the heart of protecting the global system against pandemics. Low-income countries need to feel confident that reporting a potential health problem will lead to early assistance. High-income countries should invest in public health surveillance in low-income countries, the best way to ensure an early warning against impending threats.
More contentious will be whether to introduce enforcement mechanisms within the regulations to restrict excessive measures. One consideration would be to work with the World Trade Organization to address disputes over travel and trade restrictions being applied when they are not supported by scientific evidence.
Leadership will be needed to reestablish trust and cooperation in the wake of this Ebola outbreak. The WHO must be transparent on what transpired during Ebola and provide more clarity as to how they formulate their recommendations. But despite their limitations, the International Health Regulations are an essential mechanism to help avert the international spread of disease and protect lives around the world. Countries such as Canada and Australia, which have exceeded the recommendations by imposing travel restrictions, should also be required to explain their reasoning.
The world cannot go back to the destructive isolationism of the 19th century. We need to continue to build a global response mechanism to deal with pandemics. That mission cannot be the final casualty of the Ebola outbreak.