1. The outbreak of ebola appears as though it will, in the end, constitute a legitimate public health disaster for rural communities in eastern Sierra Leone, Guinea, and Liberia. Presently, if effective border controls are not enacted to control the spread of the disease across national frontiers, it might spread to Guinea Bissau, Senegal, Côte d'ivoire, Mali, and beyond.
Several factors appear relevant to the prevalence of deaths from ebola and to the spread of the disease across national frontiers in West Africa. First, rural areas in the affected countries are liable to suffer from a lack of readily available public health facilities to quarantine ebola patients and treat them with a satisfactory expectation that such individuals will recover (for a good summary on the current state of the recent ebola outbreak in Africa and globally, see BBC News, "Ebola: Mapping the Outbreak," 17 Oct. 2014, at: http://www.bbc.com/news/world-africa-28755033). As of October 12, the World Health Organization reported a deficiency of 3,262 beds for identified ebola patients across Sierra Leone, Liberia, and Guinea, with a deficiency of over 2,300 beds in Liberia, which has experienced the largest concentration of infections. As a result of such deficiencies and concomitant deficiencies in health care staffing and community outreach in isolated rural areas, individuals who are symptomatic for ebola infection at a local level are not being adequately treated for symptoms and not quarantined to prevent further infections.
In my understanding, the particular geographic concentration of outbreaks at the juncture of the countries in Guinea's Guéckédou prefecture is instructive of how the current outbreak may have spread from its geographic base outward (see map below, however much the inclusion of Nigeria in denoting deaths from ebola is dated - Nigeria has today, as expected, declared itself to be free of ebola infections). The highland region in southeastern Guinea/eastern Sierra Leone/northeastern Liberia where the outbreak originated is highly rural and poorly serviced by health care facilities, with the largest urban concentration and service capacity at Guéckédou in Guinea. The geographic dispersion of deaths from ebola shown below seems to suggest, however, that, at least to some extent, individuals from the highland regions where the ebola outbreak originated are leaving for the coast (perhaps in an effort to escape communities already hit by the disease, perhaps to seek treatment at hospitals in the urban centers) and taking ebola with them. Thus, Conakry, the Guinean capital, shows a concentration of heightened ebola death rates. Similarly, Monrovia, the Liberian capital, had to declare a quarantine of the entire outlying penisular slum community of West Point, where ebola infections were reported. We might, finally, note that the presence of ebola deaths in Nigeria, not to mention the arrival of a Liberian ebola victim in Texas, resulted from the departure of individuals infected with ebola from regions in one of these countries where ebola pathogens were in active transmission.
The key point to be gleaned from this geographic dispersion, as a function of the particular transmission media for ebola pathogens (i.e. direct contact with bodily fluids from an individual experiences symptoms of the disease), is that there is not apt to be any contiguous geographic field for infections. That is to say, we might expect to see large concentrations of ebola infection in Lofa county in northeastern Liberia with little or no infections in, say, River Gee county near the border with Côte d'ivoire; relatively few ebola infections at Bo in central Sierra Leone but growing numbers of infections in Freetown, the capital; and stable numbers of new infections in Conakry but the appearance of ebola infections in Parisian suburbs with significant circulating populations from Guinea. In the spread of ebola pathogens, we are dealing with a very specific and peculiar network, with its own transmission media and, at least potentially, a wildly discontinuous geographic dispersion! It is not, therefore, unreasonable to expect that individuals, flying in from Monrovia, infected with ebola but not yet symptomatic (it apparently takes 21 days) might show up at Kennedy International Airport to transit to some other urban site in the U.S. We live in a fully globalizing world in which borders are increasingly becoming irrelevant!
As such, it is not my intention to press any arguments in this post in regard to border controls, especially not in the West African context. Like many other issues that have hitherto arisen within American political discourse, ebola needs to be treated as a (global) public health problem - not as an immigration/population control issue (notwithstanding the miserly beliefs of certain Americans that we don't either hold a stake in the health and welfare of populations half way across the world or possess some deeper moral obligation, as one of the wealthiest nations on the planet, to protect human life in fragile circumstances even when the lives at stake are not those of our fellow citizens!). Granted, it would help the world greatly if Sierra Leone, Liberia, and Guinea could restrict population movements from infected regions, but, to date, they have been unable to do so. Rather, the advanced/well endowed corners of the world need to do a better job helping to fight epidemic outbreaks within poorer states.
2. The death rates among West African populations infected with ebola appear to be conditioned by a range of socio-cultural, economic, and environmental/ecological factors that make the occurance of the disease an effective death sentence for those infected. We should not expect similar death rates among affected populations outside of West Africa.
Following from the logical conclusion that it may be very difficult to prevent the flow of ebola outside of Africa (at least as much as it was difficult in our species' infancy to prevent the flow of human beings out of Africa!), I think that we need to ponder the consequences from having to deal with ebola in non-African contexts. This section specifically seeks to draw a distinction between health systems, living standards, rates and characteristics of urbanization, public investment in sanitation systems, and, for that matter, built ecology, on the one hand, in West Africa, and, on the other hand, in North America, Europe, East Asia, and, to some extent, urban South America.
A relevant comparison to what is happening in eastern Liberia, Sierra Leone, and Guinea might be the outbreak of bubonic plague in late Medieval Europe. The critical point is that populations suffering from vast disparities of wealth in addition to generalized depressed living standards and deficient levels of economic development above basic, biological subsistence for the general population are also likely to be filled with individuals characterized by relatively weakened immune systems and diminished resistance to pathogens. With regard to economic development, each of these countries has suffered the trials and tribulations of market fluctuations in basically agrarian or extractive economies, with many segments of rural populations operating at the level of biological subsistence. Moreover, Sierra Leone and Liberia have both endured recent civil wars, while political instability in Guinea has left it too on the brink of civil war several times over the last two decades. Such chronic instabilities in state political regimes have, likewise hindered the sort of capital investment that might promise rising standards of living on a national level and significantly healthier, better nourished households, with extensions of basic public services like sanitation. Each of the countries houses primate cities with significant accumulations of rural populations coming into overcrowded peripheral slum areas, the worst of which is the West Point peninsula in Monrovia. Additionally, considering the ecological features of each country, it should not be forgotten that we are dealing with a tropical climate, with relatively elevated temperatures for much of the year. Finally, ebola is not alone as a significant deadly pathogen afflicting human populations in these countries. Malarial infections spread by mosquitoes are also common. When these considerations are taken into account, against the lack of available hospital facilities and quarantine spaces, an explanation becomes evident for why death rates from ebola infections as high as seventy percent have been reported.
It suffices to say that, notwithstanding the absence of a universal "cure" or vaccination against ebola, we will discover that the two American nurses infected by Thomas Eric Duncan will stand a much greater chance of surviving ebola with minimal complications than the average ebola patient in West Africa. Apart from one health care worker in Germany who died from complications related to an ebola infection received in West Africa, I have not heard of any Western health care provider who has died from an ebola infection received during the current outbreak. Today, I heard on the evening news that a photo journalist with NBC news has been cleared of ebola infection. The same is also apparently true for one of the Dallas area nurses that treated Mr. Duncan and for a Spanish nurse who treated an ebola patient entering into that country. What might this tell us about the disease except that it is extremely susceptible to differences in the environmental contexts into which it is transferred and those in which patients are treated?
3. Contingent to perceived differences in the pathogenic effectiveness of ebola in Western contexts, we need to craft policies concerning the entry and movement of individuals from the West African countries where the recent ebola outbreak has been centered that will both preserve existing standards on free movement of individuals (conditioned, as well, by other controls on the entry and movement of non-U.S. citizens) while simultaneously recognizing that judicious tracking and surveillance of such individuals will minimize the potential for transmission of ebola within the U.S. population.
This is my way of saying that I think the policies heretofore adopted by the Obama administration on the specification of treatment protocols for health care workers, reservation of hospital facilities for potential quarantine of ebola patients, and screening/surveillance/contract tracking of entrants in airports with direct flights from Guinea, Sierra Leone, or Liberia are both reasonable and warranted. Conversely, while it may be worth considering other, more rigorous options to control and track movements of individuals coming from West Africa, we need to ponder what the various consequences would be if we enacted complete travel bans from these countries and what might, in the end, be gained and lost from enacting more rigorous entry controls and quarantine policies. I do not, in this respect, want to suggest that a travel ban, especially a selective one, might not be a reasonable step, but I do think that such efforts would have unintended negative consequences and that the demand for such policies both reflects and sustains, at least in some measure, the sort of hysterical reaction to the risk of ebola that certain groups in the American political establishment have nurtured and benefited from.
First, it seems fully intuitive that a travel restriction against entry by individuals from Guinea, Sierra Leone, and Liberia would enable U.S. Immigration and Customs Enforcement officials to unambiguously nullify any threat of an ebola epidemic in the U.S. On the other hand, we would have to consider the nature of the restriction being enacted. If U.S. aviation authorities banned direct flights from Guinea, Sierra Leone, or Liberia, then individuals from these countries would still be able to enter the U.S. by flying in through a third country, as Thomas Eric Duncan and, now, Dr. Craig Spencer, a New York physician who returned with ebola after treating ebola patients in Guinea, both had (both had flown into the U.S. from Brussels). Evaluated in these terms, we would also need to reconsider the potential effectiveness of the Obama administration's efforts to test and monitor individuals entering the U.S. is the plan is only to examine individuals coming directly from Guinea, Sierra Leone, or Liberia. If the larger principle that we should be screening individuals coming from Guinea, Sierra Leone, or Liberia makes sense, then it makes sense to conduct screenings based on the larger itineraries of entrants to the U.S., wherever such individuals transited from.
In another sense, an extension of the broader principle that we should be screening individuals coming from targeted West African countries to ensure that we fully account for all individuals that could have been potentially exposed to ebola would demand such an extensive process that Immigration and Customs Enforcement officials would be compelled to conduct thorough ebola testing at all air and sea facilities welcoming individuals from foreign contexts into the U.S. There is no conceivable way that we can flag every individual entering into the U.S. to ensure that each has not passed through a region in which ebola has been actively in transmission. In certain respects, maybe this is the point for certain individuals on the political right in the U.S. who assumed that the entry of all individuals from foreign contexts into the U.S. is an intrinsically bad thing! The larger issue with any screening process should not be to exclude individuals entering from foreign contexts who might conceivable be infected with ebola. Rather, it should be to track potentially infected entrants to ensure that the flow of ebola pathogens is strictly controlled and that any individuals infected with ebola receive proper medical treatment in lieu of suffering a gruesome death at the hands of the disease.
To these ends, the principle underlying mandatory quarantine for individuals who have come in contact with individuals infected with ebola does not necessarily make good sense. On the one hand, ebola is less contagious than influenza, a family of viral infections that will certainly inflict more deaths on the U.S. population than ebola this year and for many years to come. On the other hand, we are developing a much more thorough protocol on the treatment of ebola patients, capable of achieving a much higher recovery rate than is presently available to infected individuals in West Africa. Moreover, mandatory quarantines may hinder the effort to address infected regions in West Africa if the presence of mandatory quarantines prevents health care professionals from volunteering for treatment of ebola in Liberia, Sierra Leone, and/or Guinea. These considerations suggestively support a counterargument that we would be better off to permit free entry of health care professionals, advise voluntary minimization of contacts for the course of the disease's possible incubation period (21 days) (in order to make contact tracking more effective), and pursue aggressive treatment of the disease upon determination that an individual is symptomatic.
4. Much of the political and media reaction to ebola in the U.S. reflects a more generalized current against contemporary globalization evident on both the political right and left. Above all, the American response to ebola has to transcend ignorant, hysterical, and emphatically paranoid reactions against global integration, expressed by political figures and nurtured by the media, to realize our deeper obligation to assist other human beings struggling not merely with viral epidemics but also with abject poverty, malnutrition, chronic economic underdevelopment, and ecological devastation in the name of advancing a vision of common humanity in a process of mutual development and sustainment of our race and our ecology.
My conclusion here is directed, in part, at the response to ebola expressed by Texas Governor Perry, who advanced the first emphatic call for travel restrictions from Guinea, Sierra Leone, and Liberia, but also, in part, toward New Jersey Governor Christie, New York Governor Cuomo, and other governors enacting mandatory quarantines on health care professionals coming from West Africa. Moreover, it is directed against the major corporate news media and diverse electronic media outlets that have done their best to spread fear over the potential for ebola to be spread to the U.S. population. Notwithstanding evident recognitions of physical constraints on the communicability of ebola, numerous political actors, especially among Republican Party figures at the federal level, have engaged in a conscious effort to overinflate the threat of ebola and to connect to threat from open migration of foreigners into the U.S. There is something innately disingenuous in this politicization of a global public health problem in order to rouse the suspicions of American reactionary rightists against the actions and intentions of the Obama administration in responding to this event.
Emphatically, if no measures were taken to safeguard the U.S. population against transmissions of ebola from West Africa, then fewer Americans could be expected to die from ebola this year than would be expected to die from influenza, a largely preventable viral infection significantly more communicable than ebola against which fewer than half of susceptible Americans seek vaccinations! The reaction to ebola at the state and federal level is less about rational health policy than it is about generating fear over globalization and our lack of control over, especially, population flows in a world that is becoming increasingly borderless. At the present time, we operate under the misconception that we can or should be able to readily control cross-border flows. States have operated under such misconceptions for millenia. No doubt, the Han Chinese emperors in the First and Second centuries C.E. believed that their Great Wall could prevent the Hsung Nu (i.e. barbarians) from outer Mongolia and Manchuria from ravaging the landspace of Northern China. Now, we build better fences to keep out Mexicans from Oaxaca and Chiapas from crossing into Arizona with the help of "coyotes" and staff them with ever more border security and national guardsmen and women. And, for all the tax money we are expending on these efforts to make our borders secure, we are pissing in the wind! Our borders are as irrelevant to the rest of the world as the borders of other states, like those of Syria, Afghanistan, or Pakistan are to our enactments of national security policy and to flight paths of our unmanned drones.
With such pleasant thoughts in mind, our articulations of policy with respect to ebola need to respect the deadly nature of the disease against populations that are most susceptible to its impact on human life. Instead of enacting new restrictions on the movement of health care professionals seeking to assist populations ravaged by the disease in West Africa, we should be following the efforts of a state like Cuba, dispatching large numbers of health care volunteers to assist the health care communities of affected West African countries. To its credit, the Obama administration appears to be interested in meeting the need for development of health care facilities necessary to treat infected individuals, especially in Liberia - U.S. military forces have been mobilized to these ends. Nonetheless, our larger response has been schizophrenic, mixing concern and a willingness to engage productively with governments in West Africa to contain the disease and treat infected individuals with abject fear and a desire to disengage from affected countries as if we could somehow prevent the introduction of ebola to the U.S. by pretending that our borders were something other than porous.
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