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Monday December 18 2017

Health in the Midst of Globalization: An Ebola-related travel ban is more complex than you might think

Whether we realize it or not, one of the foremost health issues affecting Canadians today is globalization (1). Mobility and cross-border travel are at an all-time high. Airplanes are more than a form of transportation; they represent a world without limits. In 2013, three billion people flew by airplane on over 36 million flights (2).

With regards to the effects of globalization on Canada specifically, almost 20% of our population is foreign-born, which is the highest proportion in 75 years (3). These foreign-born people are likely to visit their homeland (3), contributing to the high rate of international travel.

Globalization is as beneficial as it is dangerous. On one hand, travellers can easily reunite with loved ones or take a relaxing vacation. Moreover, the marketplace for many goods and services has expanded tremendously, so much so that the World Trade Organization valued international trade at nearly $16 trillion USD (4).On the other hand, an emerging concern is that globalization facilitates the transmission of communicable diseases (1). A popular example is Ebola, a viral disease that has already claimed over 5,000 lives since the current outbreak began in March 2014 (5). Ebola is communicated, directly or indirectly, through infected bodily fluids from humans or animals (6). At present, cases of Ebola are concentrated in West Africa, primarily the triangle of Sierra Leone, Guinea, and Liberia, due to the interconnectedness of these countries (6).

The sudden arrival of Ebola in North America made headlines across all forms of media. Thomas Eric Duncan, the first known case of Ebola, arrived in Dallas, Texas from Liberia (7). In the process of treatment, two nurses became infected with Ebola as well. This led to an intensive contact tracing endeavour that identified 177 people for monitoring (7). While the 177 people were eventually cleared, public fear of Ebola has lingered.

A recent poll found that two-thirds of Americans would support a travel ban on airplanes from West Africa (8). Indeed, if you scroll through the comments section of any Ebola-related article, it is likely that you will find at least one proposal for a travel ban. On the surface, the proposal makes sense. If you prevent people from Ebola-affected regions from arriving in North America, the disease should theoretically remain outside of the continental borders. The Canadian government certainly subscribes to this theory. On October 31, it announced a visa restriction on travellers from Sierra Leone, Guinea, and Liberia (9). Problem solved?

Unfortunately, an Ebola travel ban demonstrates the numerous complexities that can arise from globalization. Canada has unintentionally created a larger problem than the public health problem that Ebola poses to the country.

Firstly, Canada is stigmatizing West African travellers. The travel ban allows Canadians to freely travel to and from West Africa, yet West African travellers who do not have a visa are not afforded the same right (10). This move has the potential to spark protest at home and it creates obvious damage to Canada’s international relations. Already, Theo Nicol, the Deputy Information Minister for Sierra Leone, has stated: “…the government views (Canada’s) decision as discriminatory…” (11).

In understanding the ramifications of an Ebola travel ban, it is also important to consider the larger context. Canada is one of 196 signees of the International Health Regulations (IHR), a binding treaty which orders countries to conduct disease surveillance and report any outbreaks that may occur (12). The IHR states that during an epidemic, countries cannot impose general travel bans that have not been recommended by the World Health Organization (WHO) (12). However, the Canadian government contended that its travel ban is partial, not general (10). Regardless of whether there is a legal loophole in the IHR framework, the travel ban blatantly opposes the general spirit of the IHR. If other countries decide not to follow the IHR, the long-term result could be severe underreporting and monitoring of communicable diseases (11). Knock on wood – if a disease more severe than Ebola comes along, Canada may regret its Ebola travel ban sooner rather than later.

Another consideration is that an Ebola travel ban might encourage West Africans to travel by underground, unchecked means (11). The danger, in this case, is two-fold. These illegal travellers may not receive proper and timely treatment if they encounter illness or injury. From a public health perspective, the illegal travellers pose a problem because their symptoms, disease status, and contact networks cannot be monitored.

In conclusion, the next time someone claims that the solution to Ebola is to restrict travellers from afflicted West African countries, you can tell them, “It’s a bit more complicated than that.” The solution is not as obvious as it may appear. Ebola is a perfect demonstration of the need to consider global issues when managing global diseases.

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References

1. Hoffman SJ, Lavis JN. Issue brief: Addressing health and emerging global issues in Canada. Hamilton, Canada: McMaster Health Forum; 2011.
2. Schwartz D. Aviation Safety by the Numbers [Internet]. CBC News. 2014 Jul 28 [cited 2014 Nov 8]. Available from: http://www.cbc.ca/news/technology/aviation-safety-by-the-numbers-1.2718687
3. Statistics Canada. Immigration in Canada: A Portrait of the Foreign-Born Population, 2006 Census. Ottawa: Statistics Canada. 2007 [cited 2014 Nov 8]. Available from: http://www12.statcan.ca/census-recensement/2006/as-sa/97-557/pdf/97-557-XIE2006001.pdf
4. World Trade Organization. World Trade 2009, Prospects for 2010. Geneva, Switzerland: World Trade Organization. 2010 [cited 2014 Nov 8]. Available from: http://www.wto.org/english/news_e/pres10_e/pr598_e.pdf.
5. Ebola Response Roadmap Situation Report Update [Internet]. World Health Organization. 2014 Oct 25 [cited 2014 Nov 6]. Available from: http://apps.who.int/iris/bitstream/10665/137185/1/roadmapupdate25Oct14_eng.pdf
6. Study warns swift action needed to curb exponential climb in Ebola outbreak [Internet]. World Health Organization. 2014 Sept 22 [cited 2014 Nov 7]. Available from: http://www.who.int/mediacentre/news/releases/2014/ebola-study/en/
7. Lupkin S. Last Person Completes Ebola Monitoring in Texas [Internet]. ABC News. 2014 Nov 7 [cited 2014 Nov 8]. Available from: http://abcnews.go.com/Health/person-completes-ebola-monitoring-texas/story?id=26742640
8. Macdonald N. Can Fortress North America Keep Ebola at Bay? [Internet]. CBC News. 2014 Oct 21 [cited 2014 Nov 8]. Available from: http://www.cbc.ca/news/world/can-fortress-north-america-keep-ebola-at-bay-1.2806339
9. Canada suspends visas for residents of west African Ebola outbreak countries [Internet]. The Guardian. 2014 Oct 31 [cited 2014 Nov 8]. Available from: http://www.theguardian.com/world/2014/oct/31/canada-ebola-suspends-visas-west-africa
10. Branswell H. WHO doesn’t approve of Canada’s Ebola visa ban [Internet]. The Globe and Mail. 2014 Nov 8 [cited 2014 Nov 8]. Available from: http://www.theglobeandmail.com/news/national/who-doesnt-approve-of-canadas-ebola-visa-ban/article21513746/
11. Ebola visas [Internet]. CBC The National. [cited 2014 Nov 8]. Available from: /player/News/TV+Shows/The+National/ID/2588695883/
12. International Health Regulations [Internet]. World Health Organization. [cited 2014 Nov 8]. Available from: http://www.who.int/topics/international_health_regulations/en/

Image from http://www.cdc.gov/vhf/ebola/

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