Cruise ships, travel restrictions and fear

Bust and Plaque at the Fighting SARS memorial, Hong Kong

It is time for a hard discussion in the field of global health. In an earlier blog post I talked about how quarantine saved American Samoa during the 1918 influenza pandemic, whereas Western Samoa (now Samoa) lost nearly a quarter of its population. In the latter case, a single ship from New Zealand named the Tahune brought the virus. This video, “1918 Samoa & The Talune – Ship of Death” on YouTube shows the impact that this single ship had on the island’s history. At that time decisions about quarantine and trade were not made by the island’s inhabitants themselves, but rather by colonial administrators. Similarly, in Labrador the Moravian supply ship Harmony brought the 1918 influenza to Indigenous communities, which destroyed some entire population centers. You can see the human cost of this experience in the video, “The Last Days of Okak,” which Newfoundland archives has placed on YouTube.

The point with these two examples is that neither of communities that were affected had any say in the travel restrictions that could have protected them. Those decisions were made elsewhere. In American Samoa a harsh quarantine saved people. Of course there were economic costs to the quarantine, but those were ephemeral, whereas the lost lives in Western Samoa were permanent. But there is another lesson to the experience of these islands. The case fatality rate for the 1918 influenza was perhaps two percent globally. But there were communities (such as in Alaska) where the fatality rate was drastically higher. Some populations are more vulnerable than others, based on isolation, poor health care facilities, economic deprivation, lack of sufficient living space, and other factors. As in 1918, we may see drastic differences in fatality rates with COVID-19.

My point is that global health authorities must be very careful when pushing countries not to enact travel restrictions, or to accept passengers from cruise ships. Indeed, cruise ships are quickly becoming a horrifying example of what can happen in a constricted space. As I write these words, there are 542 confirmed cases of COVID19 (the novel coronavirus) on the cruise ship Diamond Princess. As others have pointed out (Carlos del Rio on Twitter), that is more cases than all the rest of the world outside China combined. Medical experts at this point are uncertain as to how the number of infected could continue to climb when people have been in isolation for an extended period. So far perhaps 40 percent of the people testing positive in the Diamond Princess are either asymptomatic or -perhaps better put- presymptomatic. A new article in the Journal of Infectious Diseases describes apparent transmission of the virus in China during the incubation period. As others have said, it’s not yet clear how important this form of transmission will be. Perhaps more importantly, there are also questions about how effectively quarantine procedures on the ship were implemented.  There are difficult debates underway as to how to address the needs of the passengers and also the crew. But as I write these words there is an article in the BBC News saying that passengers who have tested negative are now being taken off the ship. They are getting into taxis and going home. They will be checked on occasionally.  Of course the challenge with this approach -if this information is true- is that people may initially test negative, while still being infected. If the quarantine so far had been effectively implemented  this would be less of a worry.

Travel restrictions have pros and cons, and their use depends on context. When making a decision on enacting travel restrictions one has to balance human rights and International Health Regulations against human lives and the needs of vulnerable populations. Recently, the Prime Minister Cambodia decided to accept passengers of a cruise ship called the Westerdam, perhaps in part because of international pressure. At the time there were no identified cases of COVID19 aboard. The passengers disembarked. The Prime Minister was present to greet them. According to the New York Times the Prime Minister’s bodyguards made people take off their face masks. According to the New York Times as well some of the passengers toured Cambodia, to visit the beaches and take massages. The head of the World Health organization thanked Cambodia for taking the passengers. Then one passenger (and likely their spouse) proved to have COVID 19. The cruise company and Cambodian government questioned the first test. Then a second test was positive. We won’t likely know what happens for six days, the average incubation period for the virus. And we won’t know the real consequences for this decision for a few months. But millions of Cambodians have been put at risk, in a region with a weak health care system. One expert interviewed by the New York Times called it a potential turning point in the history of the epidemic.

There are a number of experts in global health law and experts who are denouncing travel restrictions as a violation of International Health Regulations, human rights and the advice of scientific experts. They laud Canada, for example, for not enacting travel restrictions. But decisions about public health are also contingent upon risk, and must take into account both the broader context and human lives. We must also listen to the voices of the communities at risk, so that health care decisions are only made by people in international organizations or government offices far from the places where these choices make an impact. What voice did people in Cambodia have in this decision? These experts are expressing their honest convictions. But what if they are wrong? Travel restrictions have pros and cons, and can be driven by xenophobia and racism. These measures are perhaps unlikely to work in the long term. But there is so much that we don’t know, and so many scientific questions remaining, that some humility is in order. It was not so long ago that medical experts were arguing that we lacked evidence that there were cases of human to human transmission.

Experts are becoming increasingly pessimistic that this virus can be contained. Like many of you, I have been doing the math. Assuming 329 million Americans and a fifty percent attack rate (perhaps a too conservative number) and a 2.2% fatality rate we would see over 3.6 million dead in the United States The number of global dead would reach nearly 84 million. Of course this is a back of an envelope calculation that can not capture a highly complex process. One of the lessons of 1918 was that case fatality rates could vary widely amongst populations from the relatively low (as mysteriously seems to have been the case within China itself) to catastrophic, as in some Alaskan villages. But what is  worrying that a large portion of serious cases with this novel coronavirus require intensive care units, and then take a very long time to recover. What would happen in a nation like Great Britain or Canada in which there is already a serious shortage of beds? How would people who need dialysis or chemotherapy receive care when the health care system was overwhelmed, which is already happening in Wuhan, China? And what would happen if a significant percentage of health care workers themselves fell ill, or needed to care for family members? Of course, none of this may come to pass. None of this may come to pass.

I am not trying to be alarmist, but realistic. I am currently waiting to hear if I have won a grant that would allow me to spend my sabbatical studying the 1918 pandemic in China. And a pandemic perhaps as great as 1918 is looming. Of course, the WHO -with the memories of H1N1 in mind- is reluctant to declare a pandemic even now. But it probably is one. The mathematical models show that there are likely undetected cases circulating in countries outside of China. Given the cross-border trade between China and Mynmar/Burma (to take but one example) how likely is it that the virus is not circulating there?  Look what has happened in Wuhan in less than three months, with a virus that likely started to circulate in early December, and the largest quarantine measures in modern history. Currently it may be that one tenth of the global population is experiencing some form of quarantine in China, as others have pointed out. Lately, the number of new infections in China has declined slightly. Sadly, this success will likely slow not stamp out this virus, and other countries are unlikely to be able to manage such a quarantine. New cases are continuing to appear even in Singapore, which has one of the best health care systems in the world.

Until now, like most people I have been mainly worried about panic and over-reactions based on fear. It will likely prove the case that screening, travel restrictions and quarantines cannot permanently control  the virus, outside of some island nations. But all of these may prove to appropriate tools in particular circumstances. What is appropriate for small island nation in the Pacific or Iceland may not be the same as for France. Even within nations, different states and provinces may need different approaches. What is appropriate for Puerto Rico or Nunavut may not make sense for New York or Toronto. If nothing else, we have been given the gift of time, which the people in Wuhan were not. But that’s only useful if we use it. The moment for sustained planning and action is now.

I very much hope that I am wrong. As with MERS in Korea, or SARS in 2003, perhaps rigorous public health measures can control this. In 2009 the world thought that it might be facing a pandemic, but the H1N1 virus that circulated had a low case fatality rate. But I look at the experience of the Diamond Princess, and I wonder what will happen if CORONA-19  moves into poor, high density communities in India or Kenya, where access to health care may be limited.

I think that it’s time to think very hard about the back of the envelope calculations what everyone can do. And what that means. One person out of every fifty that you know could die in a short period. Several others might be seriously ill, and spend extensive time in the hospital, and further months in recovery. We need sustained and serious emergency planning now, to slow the pandemic, create additional spaces for hospital beds, stockpile medicines, prepare drug supplies of promising medications, and many other measures. And we need to buy time. All of China is moving education online, from inner Mongolia to the coast, and grade schools to universities. It’s incredibly difficult to do so, and they are needing foreign help. If we really had to, how would we do that here? I hear nothing amongst planners about how this could be done at scale, as if such social isolation measures would never have to happen in the United States or Germany, South Africa or Brazil. Hopefully, such plans will never be needed. It’s also good to remember that the disaster scenarios might not take place, just as in 2003 or 2009.  Still, it is better to do the planning and then to not need it, than to really need it and not to have done it.

Lastly, my thoughts are with people in China who are sacrificing and suffering to control this epidemic. I have talked to friends and contacts there, who have been in their homes for over two weeks, or are rushing to put their courses online under great time pressure. The health care workers have done truly heroic acts. I recently heard appalling stories of racism and xenophobia here in the United States, including a violent case that was described to me (second-hand) by a Chinese teacher.  This must be stopped. Conspiracy theories have emerged with every pandemic. And they have led to the targeting of entire populations, as happened with European Jews during the Black Death in 1348. Anyone who is on social media will see toxic discourse. Part of our response to this outbreak must involve an effort to fight racism and xenophobia, as well as the conspiracy theories that feed them.

Shawn Smallman, 2020

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