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. …

Coronavirus and Quarantine

Health education poster, Hong Kong. Photo by Shawn Smallman

As I write these words nurses in Hong Kong are on strike to protest the fact that the Chief Executive, Carrie Lam, will not close the border to China. To be clear, the executive has sharply restricted entry to Hong Kong, closed most crossings, and forbidden entry from the most affected Chinese state, Hubei.  But there are still strong calls for a complete border closure coming from within Hong Kong’s medical community.  Similarly, the United States has restricted flights from China to U.S. citizens only; some U.S. airlines had already canceled service to China. All such quarantine measures are controversial.

On social media, such as Twitter, and in the press, a number of experts have denounced all quarantines as being not only ineffective but also in violation of WHO guidelines. These authors worried about panic overcoming good judgement, the economic costs of restricting travel, the stigma imposed on those from affected areas (Chinese in particular, but also all Asia), and the importance of upholding International Health Regulations. These are valid and important points. Some authors have also pointed to studies based on computer models showing that quarantines are ineffective with highly contagious respiratory diseases.

Recently the tone has shifted in the discussion, as it has become clear that some cases of the virus are being spread asymptomatically. The number of cases has grown quickly. Some apparent facts (such as no human to human transmission) that seemed true in mid-January are no longer true. So the stridency of the debate about quarantine has declined, but the debate continues.

So is there any role for quarantines to manage such a pandemic? And is there some other way to make a judgement that relies less on computer models? I would suggest that looking at the past history of respiratory pandemics, such as the 1918 influenza pandemic, might be useful. Can history suggest particular circumstances in which quarantines may work? …

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