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10/14/2014

Contain AND Extinguish

Dr. Tom Frieden, Director of the Centers for Disease Control, wrote an article published on October 9th entitled, “Why I don’t support a travel ban to combat Ebola outbreak.” In it he provides ten arguments against a travel ban; these arguments can be categorized as those claiming that such a ban would be ineffective, harmful, and unnecessary. Unfortunately for Dr. Frieden, they raise more questions than they answer, and do not convince that a travel ban is unhelpful.

He begins by claiming “It’s not feasible to build a wall,” and that a travel ban would be essentially a “quarantine” for Liberia, Sierra Leone, and Guinea. Frieden adds that “quarantining huge populations doesn’t work”. How a travel ban would not have prevented the US’s two cases to date—one patient a traveler, and the other a nurse who cared for him—is not apparent. It is also not apparent how travel restrictions (a ban being only one option) do not work in general, for Frieden merely makes an assertion. It is just as easy, and perhaps more appropriate, to note that fighting individual cases involves exactly that, and that successful work against Ebola within healthcare facilities and communities does as well.

Frieden spends much more time describing the harms from a travel ban. He reports that a ban would drive patients underground, and cause other countries (presumably those who learn they have Ebola cases and fear a travel ban) to “stop working with the international community.” This begs the question what “underground” means, and if whatever that is presents more of a risk for spread of the disease. Whether other countries would stop working with us depends largely on our threshold for instituting a ban, for it seems unreasonable to institute a ban for small numbers. Is anyone arguing that two cases in the US ought to result in a ban against Americans leaving the US?

He also describes how a travel ban would mean we could not get Americans out, nor medical aid in. These arguments are the most specious, for we can certainly get out any American through military or other arranged flights, and travel restrictions would not have to apply to the arrival of medical supplies and personnel to the affected West African nations.

Frieden closes by listing actions other than a travel ban that are being taken that will suffice to protect the American people, including the screening in the affected countries of people prior to departure, as well as upon arrival.  If these will prove to be sufficient it is too early to know for sure, but they are no guarantee of additional cases arriving—most, but not all, inbound travelers from affected countries are being screened. Unfortunately, confidence in their effectiveness is also not achieved by descriptions of the screening methodology, including Frieden’s less-than-reassuring comment that, “if there’s any concern about their health, they’ll be referred to the local public health authority for further evaluation or monitoring.”

What hurts Frieden’s argument the most is own glaringly faulty argument from the analogy that fighting Ebola is like fighting a wildfire: “When a wildfire breaks out we don’t fence it off. We go in to extinguish it before one of the random sparks sets off another outbreak somewhere else.” But only going in to extinguish a wildfire works only when it’s not “wild,” that is, spreading rapidly. Then the fire has to be contained as well as extinguished. Internet searches of the subject produce findings such as this: “The basic principle in fighting forest fires is to create a gap, or firebreak, across which the fire cannot move.” Frieden’s argument would work only if the effort to extinguish were so robust that containment is not necessary. Testimony from the ground states otherwise: http://www.doctorswithoutborders.org/news-stories/voice-field/ebola-fighting-forest-fire-spray-bottles

One lesson learned from reading Dr. Frieden’s article is that to include arguments so easily refuted only hurts one’s position. And what further hurts his argument is the news of the vast amount of resources consumed in our country from handling just two cases, as well as for suspected cases. These efforts only detract from our ability to send medical support such as scarce supplies to the nations in need…and to provide care to our own people. We now need all clinics, emergency departments, and hospitals to maintain robust procedures and supplies to handle suspected cases. Consider the enormous and ongoing costs to the Dallas community from just one imported case of Ebola. The arrival of even a suspected case of Ebola at a healthcare facility results in it being cordoned off, rendering it inaccessible to other patients, either by fiat or fear.

A robust response within the affected countries is needed, as Dr. Frieden indicates. But it does not preclude other measures necessary to prevent the spread of Ebola and diversion of desperately needed resources. If the cases in the US grow in number, the costs will grow exponentially, for even the current CDC case definition (reliant on known exposure or travel from endemic areas) could be threatened. As the flu season approaches, and more and more patients appear in healthcare facilities with fever and vomiting, anything other than high certainty that Ebola is nowhere around will lead to a startling disruption of healthcare in our own country.

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