In the winter of 2009, just as the swine flu epidemic was peaking in New York City, I was a medical resident working in the ICU at Columbia Presbyterian Hospital in Manhattan. The viral epidemic swept across the U.S., causing 265,000 hospitalizations and over 12,000 deaths, according to the Center for Disease Control and Prevention (CDC). The New York City Department of Health, headed then by Dr. Tom Frieden, now director of the CDC, led a campaign encouraging hand washing and vaccination.
Quarantine for patients or health care workers was not considered a valid option during that epidemic, but now with one imported case of Ebola in New York City, quarantine has been implemented in several states in direct opposition to experts at the CDC and World Health Organization (WHO). Fear and politics, not science, are the reasons behind these contrasting policies.
The differences between influenza and Ebola are striking, as are the different responses from the public and the state governments. Influenza is spread by respiratory droplets, meaning that a sneeze or cough can spread it, while Ebola requires direct contact with infected bodily fluids, an intimate occurrence not common on a subway or airplane. Left in the community, a person symptomatic from Ebola will, on average, infect two other people, while influenza patients will infect three others and measles as many as eighteen people.
Ebola is a relatively new and exotic disease, and the unknown is more frightening than any organic illness, driving us to make choices that aren’t necessarily in our best interest. We’ve seen fear provoke other questionable decisions: Parents’ unfounded fears of vaccines lead tens of thousands to opt absurout of vaccination, even though measles is one of the leading causes of death in children worldwide. And during the AIDS epidemic in the 1980s, people were fearful of methods of transmission that science had already proven wrong. Now, in retrospect, history shows that fear was misleading.
Society has a long history of stigmatizing and fearing those with infectious diseases. In the 14th century, as the bubonic plague ravaged Europe, ships’ crews were not permitted to disembark for 40 days for fear of spreading disease. Given the lack of scientific knowledge about the mode of transmission and absence of antibiotics to combat the bacteria that causes plague, quarantine may have been a reasonable approach to disease containment. Unfortunately, the rats that carried the plague to cities could still disembark from ships docked in port.
In the 21st century, however, quarantine could actually increase the severity and length of the Ebola outbreak. Quarantining all those who are exposed to the virus, even those who are asymptomatic and are thus not able to transmit the disease, will likely decrease the number of aid workers from developed countries who will volunteer to work in the affected areas. As a result, there will be a more severe and prolonged epidemic in West Africa which will increase the number of people who can bring the disease into the U.S. and Europe over the long term, and will cause thousands more deaths. A travel ban would only force those people underground, making case identification and contact tracing much more difficult.
It may not be unreasonable for developing countries with weak public health systems to ban travelers from West Africa or to implement quarantine. In Port-au-Prince, Haiti, we’ve witnessed the importation and spread of cholera and, more recently, the Chikungunya virus and have seen the difficulty of containing infectious diseases in low-resource settings. The U.S., however, has indoor plumbing to dispose of infected waste and no dense populations living in extreme poverty where diseases spread by bodily fluids can flourish. The U.S. has the most advanced health care in the world, including hospitals with isolation rooms and medical staffs that are accustomed to donning gowns and gloves for patients with MRSA.
For all the intense scrutiny over plane flights and bowling excursions of those exposed to Ebola, there have been no infections in the U.S. that were contracted outside of a hospital setting. With no symptoms and a negative blood test, nurse Kaci Hickox is not a threat to those around her. Doctors Without Borders, the organization that she worked for, has been working with Ebola patients throughout Africa for years. Currently, only three of the 700 international staff have contracted Ebola while working ion related projects, but hundreds of patients have been treated, preventing further spread of the disease. The irrationality of mandatory quarantine for a nurse returning from Africa while those who treat Dr. Craig Spencer in New York City are free to return to their homes reveals the hypocrisy that underlies the political decisions. Hickox and Spencer deserve to be treated as heroes to humanity, not as sailors attempting to offload from a 14th century vessel.
The CDC guidelines for Ebola containment are based in science, not the politics of fear. We must remember that the CDC is the organization was at the forefront of eradicating smallpox, discovered how HIV was transmitted and regularly investigates outbreaks of food-borne illness or STDs. Politicians would do well to listen to the expertise offered by the CDC, Doctors without Borders and the World Health Organization. The federal and state governments might better allocate their public health resources by sending more medical personnel to the affected countries instead of enforcing an expensive and potentially disastrous quarantine or travel ban.
From SARS and swine flu to Dengue and Chikungunya, we cannot prevent importation of infectious diseases without addressing their root causes, all of which are exacerbated by poverty and weak public health systems. Without relying on the science that we’ve learned through experience and research, we risk falling back to the dark times of the 1980s, or worse, to the 14th century.
Vincent DeGennaro is an internal medicine doctor and a global public health specialist at the University of Florida’s Division of Infectious Diseases and Global Medicine and works half time in Haiti with the nonprofit Project Medishare. See his An American Doctor in Haiti blogs.