By David Fisher
With the largest outbreak of one of the world’s most frightening contagious diseases raging in Western Africa, is it time to lift travel bans to the affected countries?
Flight restrictions have blocked or slowed relief efforts at a time when key first-line responders to the Ebola outbreak in West Africa, such as Médecins Sans Frontières (MSF) and the International Federation of Red Cross and Red Crescent Societies (IFRC), are still urgently calling for a greatly increased international response.
Over a dozen countries have instituted bans on travel from the EVD-affected countries and ten airlines have restricted or terminated their routes. Meanwhile, the World Bank notes that border closures are driving up food prices in the affected countries, and it is magnifying the “wave of fear” (both domestically and internationally) that threatens a short-term impact ranging between 2 and 3 percentage of GDP of Sierra Leone, Guinea and Liberia.
Lifting travel bans may seem like a hard sell, but it has an impressive roster of proponents, ranging from the World Health Organization (WHO), to the International Civil Aviation Organization, the African Union and, in a historical first, the UN Security Council, by means of resolution with over 130 co-sponsors (the most ever).
How can this make sense? Ebola virus disease is not airborne, but is spread relatively easily upon direct contact with bodily fluids from a symptomatic person or dead body. It is also very deadly – with an average fatality rate of 50 - 60 per cent in this outbreak. Infected persons can carry the disease without symptoms for up to 21 days, meaning that someone could certainly travel quite far without raising suspicions before s/he starts to appear ill (and becomes contagious). Moreover, the current crisis has already largely surpassed all prior Ebola outbreaks, spreading from Guinea to Sierra Leone, Liberia, and Nigeria, with 4,877 deaths and 9,936 confirmed cases as of 22 October. Experts warn that these numbers may climb exponentially if efforts are not scaled up to contain the spread.
Yet, WHO has repeatedly advised against blanket travel bans, urging instead that states only forbid travel to persons showing symptoms and ensure that they have adequate diagnostic facilities available. It argues that blanket bans are rarely successful in any case, that EVD, unlike airborne diseases, is unlikely to spread without direct contact, and that they will isolate and stigmatize the affected countries, cutting off routes for humanitarian assistance and ravaging their economies. In addition, as recently argued by United States Center for Disease Control and Prevention Director Tom Frieden, “We really need to be clear that we don't inadvertently increase the risk to people in this country by making it harder for us to respond to the needs in those countries. By making it harder to get assistance in and therefore those outbreaks would become worse, go on longer, and paradoxically, something that we did to try and protect ourselves might actually increase our risk."
IFRC Secretary-General Elhadj As Sy agrees: "It [Ebola] creates a lot of fear and extreme panic that sometimes leads to very irrational types of behaviours and measures, like closing borders, cancelling flights, isolating countries etc... The only solution is how can we join our efforts to contain those kinds of viruses and epidemics at their epicentre, right where it starts."
The role of international law
In 2005, the member states of the World Health Assembly adopted a revised version of the International Health Regulations (IHR), a treaty designed to balance the clear global need for states to share information and take vigorous steps to monitor and contain epidemics that might spill over borders, with states’ fear of the economic impacts of being labelled the source of contamination.
According to article 43 of the IHR, states may implement extraordinary “health measures” in the face of pandemics, so long as they are not barred by IHR and are “no more restrictive of international traffic and not more invasive or intrusive to persons than reasonably available alternatives that would achieve the appropriate level of health protection.” In making this determination, they are expected to weigh scientific principles and evidence as well as the specific advice of WHO, and also to inform WHO of their rationale. While certainly impinging to some extent on states’ freedom to act, this provision also still leaves states some leeway to justify strong measures, even if contrary to WHO advice.
In addition to this, the UN Security Council and the AU Executive Council have issued historic calls (among other things) for the revocation of travel bans on the EVD-affected countries. Both of these bodies have the authority to issue legally binding orders to their member states. However, it is not clear in this case whether they have intended to do so.
UN Security Council Resolution 2177 does not specifically state that it has been issued pursuant to Chapter VII of the UN Charter, which has become customary in resolutions intended to be binding, though, extraordinarily, it does make the required finding that the situation “constitutes a threat to international peace and security” (which may be sufficient). Likewise, the AU Executive Council Decision does not directly order states to revoke their travel bans but, rather, directs the AU Commission to “call on” them to do so.
So, it is possible, but not entirely clear, that states maintaining blanket travel bans against the EVD-affected states are failing to meet their international law obligations. So far, only the Ivory Coast has announced that it will reverse its current ban, whereas some others have stated that they will not be swayed. On the other hand, several countries (in particular the United States and Spain) with highly publicized (individual) cases of Ebola have thus far resisted imposing a travel ban.
Looking to the future
There is plainly an important place in public health practice for social isolation and movement restrictions to contain epidemics. However, experts have cast significant doubt on whether border closures and travel bans are anywhere near as effective as commonly believed.
At a minimum, it would seem critical to ensure that humanitarian personnel be allowed to travel to and return from the affected areas, subject to the specific restrictions on flight by persons actively displaying symptoms and to special monitoring of such persons upon their return. So far, the doors remain open in most countries that are sending such personnel, though contrary opinions are starting to get more attention in the media. Consideration might be given to including some specific language about how to handle access by relief workers in a future revision of or protocol to the IHR.
However, this may not be enough. Despite the adoption of the IHR and other arrangements, the international community has not yet been able to provide affected states with any real protection against economy-busting reprisals as soon as they are identified as a “source” of contagion. Mexico’s experience with the 2009 influenza outbreak is a sad reflection of this, though it has been argued that there were many more cases in the United States in the same period.
It might be tempting to sadly conclude that this is just the poor luck of the affected countries. However, without any such protection, the question is whether government will be willing to be open and cooperative about brewing epidemics in the future. This is not conjecture, inasmuch as allegations around secrecy related to the SARS epidemic in 2003 was an important impetus for the revision of the IHR in 2005. Today’s insufficiently contained Ebola outbreak is genuinely terrifying, but how much worse might it already be if it had been kept secret? - See more at: http://www.ifrc.org/en/what-we-do/disaster-law/news/africa/the-hard-sell...