The federal government has not imposed travel restrictions on travelers originating in West Africa, but the governors of New York and New Jersey have done so.
Each State Department of Health at JFK and Newark Liberty International Airports will, as permitted under applicable law, make its own determination as to hospitalization, quarantine, and other public health interventions for up to 21 days. There will also be a mandatory quarantine for any individual who had direct contact with an individual infected with the Ebola virus while in one of the three West African nations (Liberia, Sierra Leone, or Guinea), including any medical personnel having performed medical services to individuals infected with the Ebola virus. Additionally, all individuals with travel history to the affected regions of West Africa, with no direct contact with an infected person, will be actively monitored by public health officials and, if necessary, quarantined, depending on the facts and circumstances of their particular situation.
The governors’ new policy is unsurprising. The States, not the federal Centers for Disease Control, are responsible for public health. Moreover, the federal government’s decision not to impose travel restrictions increases the States’ burden in protecting public health within their borders. In short, while the federal government has sole authority over who to admit into the US, it is the States that decide what public health measures apply to them.
The distinctions made among classes of travelers in this policy has a clear risk-based component. Persons who have had direct contact are given greater scrutiny than those who have not, and persons who have delivered health care to Ebola patients are presumed to have been in direct contact. Note that the policy also gives State officials virtually unfettered discretion to decide how to handle each case (“as permitted under applicable law,” “make its own determination,” “depending on the facts and circumstances”). It is the breadth of this discretion, combined with the characteristic hyper-precaution that government employees display when they fear or expect being held accountable only for false negatives, that poses the greatest threat to competent and dignified implementation.
Anecdotal evidence suggests that actual implementation might not be either competent or dignified. Kaci Hickox, who describes herself as “a nurse with degrees from the University of Texas at Arlington and the Johns Hopkins University, has been caring for Ebola patients while on assignment with Doctors Without Borders in Sierra Leone,” found herself involuntarily quarantined at a New Jersey after her arrival at JFK. Perhaps more importantly, she reports have been treated disrespectfully and by people less knowledgable about Ebola that she:
I arrived at the Newark Liberty International Airport around 1 p.m. on Friday, after a grueling two-day journey from Sierra Leone. I walked up to the immigration official at the airport and was greeted with a big smile and a “hello.”
I told him that I have traveled from Sierra Leone and he replied, a little less enthusiastically: “No problem. They are probably going to ask you a few questions.”
He put on gloves and a mask and called someone. Then he escorted me to the quarantine office a few yards away. I was told to sit down. Everyone that came out of the offices was hurrying from room to room in white protective coveralls, gloves, masks, and a disposable face shield.
One after another, people asked me questions. Some introduced themselves, some didn’t. One man who must have been an immigration officer because he was wearing a weapon belt that I could see protruding from his white coveralls barked questions at me as if I was a criminal.
Two other officials asked about my work in Sierra Leone. One of them was from the Centers for Disease Control and Prevention. They scribbled notes in the margins of their form, a form that appeared to be inadequate for the many details they are collecting.
I was tired, hungry and confused, but I tried to remain calm. My temperature was taken using a forehead scanner and it read a temperature of 98. I was feeling physically healthy but emotionally exhausted.
I called my family to let them know that I was OK. I was hungry and thirsty and asked for something to eat and drink. I was given a granola bar and some water. I wondered what I had done wrong.
Four hours after I landed at the airport, an official approached me with a forehead scanner. My cheeks were flushed, I was upset at being held with no explanation. The scanner recorded my temperature as 101.
The female officer looked smug. “You have a fever now,” she said.
I explained that an oral thermometer would be more accurate and that the forehead scanner was recording an elevated temperature because I was flushed and upset.
I was left alone in the room for another three hours. At around 7 p.m., I was told that I must go to a local hospital. I asked for the name and address of the facility. I realized that information was only shared with me if I asked.
Eight police cars escorted me to the University Hospital in Newark. Sirens blared, lights flashed. Again, I wondered what I had done wrong.
I had spent a month watching children die, alone. I had witnessed human tragedy unfold before my eyes. I had tried to help when much of the world has looked on and done nothing.
At the hospital, I was escorted to a tent that sat outside of the building. The infectious disease and emergency department doctors took my temperature and other vitals and looked puzzled. “Your temperature is 98.6,” they said. “You don’t have a fever but we were told you had a fever.”
After my temperature was recorded as 98.6 on the oral thermometer, the doctor decided to see what the forehead scanner records. It read 101. The doctor felts my neck and looked at the temperature again. “There’s no way you have a fever,” he said. “Your face is just flushed.”
My blood was taken and tested for Ebola. It came back negative.
I sat alone in the isolation tent and thought of many colleagues who will return home to America and face the same ordeal. Will they be made to feel like criminals and prisoners?
I recalled my last night at the Ebola management center in Sierra Leone. I was called in at midnight because a 10-year-old girl was having seizures. I coaxed crushed tablets of Tylenol and an anti-seizure medicine into her mouth as her body jolted in the bed.
It was the hardest night of my life. I watched a young girl die in a tent, away from her family.
With few resources and no treatment for Ebola, we tried to offer our patients dignity and humanity in the face of their immense suffering.
The epidemic continues to ravage West Africa. Recently, the World Health Organization announced that as many as 15,000 people have died from Ebola. We need more health care workers to help fight the epidemic in West Africa. The U.S. must treat returning health care workers with dignity and humanity.
For travelers like Craig Spencer and Kaci Hickox, who have a relatively high risk of latent infection precisely because of their work caring for Ebola patients, there might be few alternatives to travel restriction by quarantine. Nonetheless, a travel restriction policy implemented incompetently and disrespectfully achieves no greater benefits than one implemented well. Incompetent implementation imposes gratuitous costs on those whose liberties are restricted in the name of public health, and that shifts benefit-cost balancing in favor of less restrictive (and unfortunately less effective) policies.