NAIROBI — As countries work to contain the global spread of the novel coronavirus, COVID-19, some are taking more drastic measures than others, including closing borders, banning travelers, quarantining foreigners, and rejecting cruise ships from docking at their ports.
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COVID-19 has infected over 82,000 people and killed over 2,800 in the past few months. The vast majority of cases are still in China, which global health officials have attributed to the Chinese government’s aggressive approach to containment, including placing a quarantine on Wuhan, the city at the epicenter of the outbreak.
“The intent early on, from public health leaders, was to contain the virus with the thought that if we can prevent the virus from getting significantly embedded within the population, we will be able to avoid far more severe consequences,” said Leonard Marcus, a public health practice expert at Harvard T.H. Chan School of Public Health.
“It is enshrined in international health regulations that countries should do their best to keep borders, travel, and trade open during these periods.”— J. Stephen Morrison, senior vice president, Center for Strategic and International Studies
But the nature of the outbreak is changing — raising questions about what role these types of restrictions will play moving forward in the outbreak. This week, for the first time since COVID-19 was discovered, there were more new cases reported outside of China than in China, with over a dozen countries reporting their first cases. There are now over 3,600 cases in over 50 countries, with cases continuing to grow.
“We are concerned about the number of cases with no clear epidemiological link, such as travel history to China or contact with a confirmed case,” said WHO Director-General Tedros Adhanom Ghebreyesus during a press conference on Feb. 21.
Border closures, travel restrictions
Coronavirus by region:
Beyond China, other countries have also taken an aggressive approach to containment. Last week, Russia announced it would temporarily ban Chinese citizens from entering the country – a move it took after closing its land border with China and Mongolia. Dozens of other countries have also instituted bans on Chinese visitors. Iran’s neighbors have closed their borders as cases in the country rise. North Korea has quarantined foreigners.
Thirty-eight countries reported to WHO they’ve instituted travel restrictions, including travel bans of visitors from China or other countries reporting transmission of COVID-19, quarantine of foreigners, self-isolation of returning citizens and visa restrictions. There have been no trade restrictions.
Countries have taken these actions as a result of fear and panic in the face of a virus which has no vaccine, no treatment, and many unknowns about it, said Yanzhong Huang, senior fellow for global health at the Council on Foreign Relations.
But others have worked to keep borders and the movement of people open. WHO’s Tedros has repeatedly called on the international community for “solidarity” in its response, applauding actions that buck the trend of isolation — such as the Cambodian government’s decision to welcome a cruise ship that ports in five countries had rejected.
Foreign ministers from China and the Southeast Asian countries met last week where they committed to “jointly maintaining people-to-people exchanges, trade, and investment activities in the region, and, based on the progress of the prevention and control of the epidemic, resume and enhance exchanges and cooperation.”
But these decisions have not always been politically popular.
While making these decisions, countries are juggling competing demands of maintaining good diplomatic relationships with China, a global economic powerhouse, while also frantically working to prevent the spread of the virus among their population.
In Zimbabwe, the government’s decision to not institute travel restrictions against Chinese citizens has drawn sharp criticisms from civil society and the main opposition political party.
“The government has hitherto concentrated on airports, yet it is reported that some people from China are crossing Victoria Falls bridge on foot. Screening and data collection should be done at all ports of entry. Non-essential travel to and from China should be minimized forthwith, because we simply do not have the capacity other nations have to deal with a coronavirus outbreak in Zimbabwe,” wrote Dr. Henry Madzorera, secretary for health and child welfare of the opposition group Movement for Democratic Change.
In recent years, Chinese investments have funded infrastructure projects in areas such as manufacturing, transportation, and energy.
“It will be tantamount to biting the hand that feeds you,” said Ronald Chipaike, international relations expert at Bindura University of Science Education in Zimbabwe.
Companies are also taking different approaches. Ethiopian Airlines, despite criticism, has committed to keeping its five routes to China open, whereas Kenya Airways has already lost $8 million from its decision to suspend flights from China, according to The East African.
Countries and companies are conducting a cost-benefit analysis when making these decisions, Marcus said.
“By closing the borders there is a significant short-term cost, but there also could be a huge long-term benefit,” he said.
While WHO has not recommended travel or trade restrictions, there is a need for WHO to issue more explicit, practical guidance that includes scenarios that outline under which situations countries should close borders and restrict travelers, Huang said.
“Unfortunately, those guidelines are not available under the international agency, so pretty much countries are on their own,” he said.
Effectiveness of travel restrictions
Many in the international community have credited travel restrictions, quarantines, and border closures with limiting the cases in countries outside of China.
“What is known is that by restricting the immigration of people who have been exposed or could have been exposed is curtailing the spread of the disease. Finding effective ways to continue doing that is going to be critical, if we are going to avoid the kind of worldwide pandemic the World Health Organization is concerned about,” Marcus said.
A preliminary analysis of travel restrictions suggested these measures “may have delayed the importation of new cases, but did not prevent the importation of the disease," WHO said, noting they “may have a significant economic and social impact.”
But as the geographic spread of the virus continues, strategies around containment have become more complicated. New cases in Algeria, Nigeria, Brazil, and in several countries in Europe, for example, were from Italian travelers. The first case in New Zealand is a traveler from Iran.
“These containment strategies have certainly had an impact, but whether they're going to be able to contain the virus over a longer period of time? We're dealing with a lot of unknowns,” Marcus said.
One of the problems with implementing travel restrictions is that it requires knowing exactly where in the world the virus is, Jennifer Nuzzo, senior scholar at the Johns Hopkins Center for Health Security, said.
Iran, for example, banned visitors from China about three weeks before it reported its first cases, reporting deaths on the same day it reported its first cases.
“When you limit travel from an area, and then in a few weeks you see cases, it suggests that you didn't have the right information of where you were supposed to limit it or that the targeted measure didn't work,” Nuzzo said. “There's always going to be a bit of a lag in our understanding of where the virus is.”
Many countries are still only targeting travelers with connections to Wuhan — the epicenter of the outbreak, or broader China, she said.
WHO has emphasized the importance of airport detections in countries that are preparing for a potential spread, focusing on flights from China. But this method has also been criticized for letting cases slip through. Estimates of the virus’s incubation period, when someone would not exhibit symptoms, range from zero to 14 days and researchers have documented a case of spread of the virus from a person who was not showing symptoms.
“These travel controls are effective if you know how to screen for the virus. The virus is very hard to detect if people are asymptomatic but also infectious,” said J. Stephen Morrison, senior vice president at the Center for Strategic and International Studies.
There should be an expansion of surveillance of the virus, experts say. This could include sampling portions of the population, Nuzzo said. Without these surveillance mechanisms, it is possible that the first cases a country will notice are the severe ones, because they will be easier to identify.
“Sample testing can help us understand if the virus is here, if it is circulating, and to keep tabs on it so that we're not caught off guard when suddenly there are a bunch of deaths. That is what happened in Iran,” Nuzzo said.
Impacts on the response, allocation of resources
There are also risks surrounding how efforts like restrictions, bans, and border closures can impact both the response and the populations these efforts target.
“It is enshrined in international health regulations that countries should do their best to keep borders, travel, and trade open during these periods,” Morrison said. “It multiplies the sense of crisis and it creates blockages to the passage of critical personnel and medical products. It’s highly problematic, in all of those ways.”
One method that has drawn criticism is the quarantine of an entire cruise ship off the coast of Japan, where 705 confirmed cases of COVID-19 accumulated following the decision to quarantine the ship.
“On a cruise ship, not only is their movement restricted, but they're restricted in a very confined space which makes it more likely that they would be able to become infected,” Nuzzo said. “There are so many more ethical and legal concerns with the way we have been managing the cruise ships and I think it's really an international public health travesty that we're seeing.”
Also, it could be problematic if governments across the world begin to quarantine populations, using militant measures, Nuzzo said.
The WHO chief has repeatedly sent his praise to China over its response to the 2019-nCoV outbreak. But there are increasing anecdotal reports that the government may not have been very responsive in the early days of the outbreak.
“If countries throw away their credibility by taking a law enforcement approach to controlling the disease and just locking down whole parts of their country, they're going to lose the support and cooperation of the public, which is absolutely essential for managing the situation,” she said.
There are also concerns about resources. Implementing travel bans and border closures can be resource intensive with unclear public health benefits, Nuzzo said.
Instead, countries should be spending resources on building capacity for a potential spread, she said. This includes considerations around improving diagnostic capacity, creating enough spaces for isolation, building up infection prevention capacity in health facilities, developing risk communication messaging and teaching communities how to conduct home-based care, as well as preparing to protect vulnerable populations, including elderly people and those with underlying health conditions.
Travel restrictions could also prevent countries from reporting cases.
“I worry about the message it sends to countries about whether they should look for cases. Is it in their best interest to report cases or is it only going to cause them economic harm?” Nuzzo said.
Nyasha Mark contributed reporting to this piece from Zimbabwe.
Update, March 2, 2020. This article has been updated to reflect the number of countries reporting travel restrictions to WHO.