The road not traveled

Travel restrictions seem to work after all, and America never tried

Greetings! Yesterday I recorded an episode of The Joe Rogan Experience that I believe should be released today so if you are interested in an extremely long (I think we went over three hours), rambling, and unfocused conversation touching on Doctor Strange, fishing, whether Bill Gates is personally profiting off vaccination efforts in poor countries (he is not), and Quentin Tarantino’s depiction of Bruce Lee check that out.

But beyond that, my hope today is to start a conversation that I’ve been meaning to have for a while. Donald Trump’s response to the Covid-19 pandemic has been not just ineffective, but genuinely clownish in a way that would be funny were it not so infuriating. He’s acted as a snake oil salesman for hydroxychloroquine, flouted public health guidelines, mused about bleach injections, and generally not even put on a halfway plausible show of having any idea what he’s doing. He’s so bad at his job that coverage of how bad he is at is has tended to suck up all oxygen in the room. A recent study by Bruce Sacerdote, Ranjan Sehgal & Molly Cook found that, from January through October, “stories discussing President Donald Trump and hydroxychloroquine are more numerous than all stories combined that cover companies and individual researchers working on COVID-19 vaccines.”

But not only did Trump’s antics crowd out a lot of good, heroic work that a lot of other people have done, they’ve crowded out a lot of other screwups that we really ought to be learning from.

We’re talking screwups from the people who aren’t clowns — from the public health experts and from the responsible media and political figures who listen to them. The most obvious example of this is probably masks, but I think the most telling example is probably around travel restrictions, which much of the western expert community was eager to declare ineffective, but have clearly been a key element of successful pandemic management strategies.

The misunderstood case against travel restrictions

Like 99 percent of political pundits, I’d never given a moment’s thought to the question of whether or not travel restrictions are a good response to emerging epidemic disease outbreaks until the West Africa Ebola outbreak of 2014.

That outbreak led many congressional Republicans to call for travel bans, an idea the Obama Administration rejected, and that argument led to a reasonable amount of political controversy. I did not cover this personally, but my colleagues at Vox did and the tenor and tone of the coverage was very clear:

• “Why travel bans will only make the Ebola epidemic worse” [Julia Belluz / Steven Hoffman]

• “Canada’s Ebola visa ban is dumb, xenophobic, and illegal” [Julia Belluz]

• “Why an Ebola travel ban is a bad idea, explained in 2 minutes” [Ezra Klein]

As is usually the case, the actual content of these stories turns out to be considerably more nuanced than the headlines. What the stories say is that the kind of travel bans that are typically imposed in such situations have been generally ineffective. In the case of something like the Ebola outbreak where there was a serious effort to contain it via contact tracing, stigmatizing the disease would have likely been counterproductive by undermining contact tracing. The stories also contain supplemental points like that airport temperature scans are ineffective at catching people at the border.

Conveniently for everyone, the Obama administration’s strategy turned out to work. We didn’t do travel bans; we did surge resources into the affected area, and we contained the epidemic. Everybody likes a good success story, and this particular one also aligned with the reality that most of the top Western infectious disease experts really cut their teeth on HIV/AIDS, where destigmatization was a critical element of a successful public health strategy.

But when you have un-nuanced headlines that are backed up by success, something that happens is people remember the headlines and not the details.

I will plead guilty here personally. I didn’t really cover Ebola. But I remembered that the Obama Administration took shit from people over not doing a travel ban; I remembered that my colleagues said Obama was right and travel bans don’t work, and I remembered that Ebola turned out fine. So travel bans don’t work.

But it turns out that while the Ebola situation was handled well, the simplified headline takeaway that “travel restrictions are bad” was not particularly based in anything.

The WHO’s travel guidance was bad

Back in late January, the World Health Organization was advising governments not to impose travel restrictions in response to the Covid-19 outbreak. At this point, again, I was following this more as a consumer of the news than as a journalist. And I thought, yeah, that sounds about right — WHO experts are saying what I remember us quoting experts as saying years ago with Ebola.

Months later on September 30, I read something remarkable in the 9th graf of a New York Times article whose lede focused on a specific ski resort in Austria:

Public health records, scores of scientific studies and interviews with more than two dozen experts show the policy of unobstructed travel was never based on hard science. It was a political decision, recast as health advice, which emerged after a plague outbreak in India in the 1990s. By the time Covid-19 surfaced, it had become an article of faith.

“It’s part of the religion of global health: Travel and trade restrictions are bad,” said Lawrence O. Gostin, a professor of global health law at Georgetown University who helped write the global rules known as the International Health Regulations. “I’m one of the congregants.”

When I read that, I was shocked that it wasn’t the lede of the story. And shocked that we didn’t have more people talking about it.

But they have the goods on this. Here’s what happened:

In the fall of 1994, a plague outbreak struck the Indian port city of Surat. Hysteria erupted, and countries quickly banned travel to India. Tourists abandoned their vacations. Airlines canceled flights. The United Arab Emirates banned Indian cargo, while Russia demanded quarantines on shipments.

Plague is not uncommon, with small outbreaks every year, even in the United States, and Surat’s outbreak turned out to be relatively mild, with just over 50 deaths. But the global panic devastated the city and cost India’s economy an estimated $3 billion.

The reaction to the outbreak alarmed David Heymann, an American epidemiologist who was then a senior W.H.O. official involved in the agency’s response to Surat. Indian officials had properly reported the outbreak and quickly brought it under control. Yet India was punished, a response he considered “irrational.”

“It had nothing to do with the outbreak,” said Dr. Heymann, who was trained at the U.S. Centers for Disease Control and Prevention.

Heymann had a specific and very valid concern about this. A plague outbreak, if reported in a prompt manner, is easy to contain — it’s treatable with antibiotics. But if reporting a plague outbreak leads to your economy being crushed by travel restrictions, then you’re not going to report the outbreak in a prompt manner. And that is clearly bad for public health.

But over the years, the laudable desire to avoid a repeat of the Surat situation and the perverse incentives it created got reified into a principle — travel restrictions are bad and don’t work — that was detached from the circumstances at hand and wrongly applied to the totally different factual situation of the Covid pandemic, a respiratory virus that we had no effective treatment for.

Trump proves the skeptics right

Trump, of course, was among the voices calling for travel restrictions during Ebola. He’s obviously a big fan of migration restrictions in general. And he’s not the kind of person to defer to bien pensant conventional wisdom from public health experts. So when Trump announced restrictions on travel from China, the coverage from public health people was highly negative.

Because Trump is childish, this became a major point of resentment for him. As he took more and more criticism for not doing enough to save Americans’ lives, he felt he wasn’t getting the credit he deserved for implementing travel restrictions that the public health establishment opposed.

But of course the plain fact is that what Trump imposed didn’t work. Not because “travel bans don’t work,” but because the policies Trump pursued were not travel bans. He exempted US citizens, US green card holders, and the immediate families of citizens and green card holders from the ‘ban’ on travel from China. That’s a majority of the people who fly between the US and China.

Which is to say that Trump essentially conceptualized this as an immigration policy issue — keep the foreigners out. But viruses don’t work like that.

Meanwhile, by late February we had dozens of cases in Northern Italy and there was no restriction whatsoever on air travel between Italy and the United States. In a normal year, there are about a million passengers traveling between Milan Malpensa airport and JFK and Newark in the Greater New York City area. We know that there were cases on the West Coast that seem to have come from Asia and now some new evidence that Covid may have been present in the United States as early as December. But whatever was going on in December it doesn’t seem to have led to significant community spread. And we know the really bad outbreak had its epicenter in New York and was of European origin.

So Trump implemented a travel ban; the skeptics argued that travel bans don’t work, and the thing that Trump did certainly didn’t work. So that’s a loss for him. But less because travel bans don’t work than because the restrictions Trump put in place weren’t any kind of ban.

Covid success stories involve travel restrictions

If you want to go to New Zealand these days, the answer is basically you can’t go to New Zealand.

That’s because New Zealand is a Covid-19 suppression success story. And while you don’t suppress the virus with travel bans per se, once you have suppressed the virus if you just let folks waltz in from the outside then your suppression is going to be defeated rather quickly. But it’s not just that you personally almost certainly can’t go to New Zealand. If you happen to fit in one of the categories of people who are allowed to go to New Zealand (citizens, permanent residency holders, diplomats, certain Australian citizens, etc.) then you need to book yourself a 14-day stay in a managed isolation facility. Before you board a flight you’ll need to prove that you have such a booking. And when you land you have to go there and quarantine for two weeks.

And that more than the question of who exactly is allowed to enter is really the essence of a travel restriction approach to an epidemic. There’s an immigration policy question about who can arrive. But the public health policy is that everyone who does arrive needs to go into a secure quarantine.

• To go to Taiwan, you need to quarantine for 14 days.

• To go to Korea, you need to quarantine for 14 days.

• To go to Australia, you need to quarantine for 14 days.

All that is on top of restrictions on who can enter at all.

Obviously this is all very burdensome. New Zealand is a small country. Looking at their success at suppressing the virus, it’s hard not to be jealous. Not only have many lives been saved, but unlike in the United States daily life can proceed on a normal basis without risking anyone’s health. But for a small country to cut itself off from the world to that extent is a hardship, both socially and economically. But this is what the successful suppression countries are doing.

For a counterpoint you can see Germany, which had an initially successful Covid approach. Then when the second wave of cases started hitting Spain then Italy and France, Germany still seemed a lot safer. But because people could travel into Germany without quarantining, inevitably their contact tracing got overwhelmed and they had a significant spike that ended up requiring harsh restrictions to get back under control.

A lot of people have made the point that many of the success stories are islands or argued that Korea is a quasi-island. But it’s important to be clear here. Covid didn’t sneak into the United States across the land border with Mexico. It arrived on planes from Europe. And it didn’t sneak in on planes either; we weren’t trying to stop the planes from coming. Even when Trump did restrict travel from Europe, he exempted American citizens and encouraged an enormous homeward bound rush of people. We didn’t fail to seal the border because we couldn’t pull it off logistically — we just didn’t try.

Americans are very resistant to travel restrictions

Once it was clear that a huge Covid outbreak was under way in Greater New York, one thing other parts of the country might have wanted to try to do was stop infected New Yorkers from pouring in to where they were. The governor of Rhode Island went furthest down the road, to the point of situating state police at freeway entry points.

This did not go over well. Andrew Cuomo threatened to sue, and Steven Brown, the executive director of the Rhode Island ACLU, denounced the idea:

“Under the Fourth Amendment, having a New York state license plate simply does not, and cannot, constitute ‘probable cause’ to allow police to stop a car and interrogate the driver, no matter how laudable the goal of the stop may be,” Mr. Brown said in a statement.

Trump eventually mused aloud about a federal quarantine order, in a way that — as Rep Tim Ryan warned — was likely counterproductive.

Congressman Tim Ryan @RepTimRyan

This only exacerbates the problem. People will now leave these areas to avoid the potential quarantine and it will further spread this deadly disease.

Donald J. Trump @realDonaldTrump

I am giving consideration to a QUARANTINE of developing “hot spots”, New York, New Jersey, and Connecticut. A decision will be made, one way or another, shortly.

Of course Trump didn’t actually do it. But politicians did talk about it for a day or so with, again, Governor Cuomo leading the charge of criticism.

Jesse McKinley @jessemckinley

More @NYGovCuomo on this: "From a medical point of view I don't know what you would be accomplishing, but I can tell you I don't even like the sound of it."

Donald J. Trump @realDonaldTrump

I am giving consideration to a QUARANTINE of developing “hot spots”, New York, New Jersey, and Connecticut. A decision will be made, one way or another, shortly.

We now know that rich people, in particular, left the city in droves. That was probably in part to flee the virus itself.

But, more broadly, the whole reason people like to live in New York is to go to restaurants and museums and theaters and other stuff that was closed. During the pandemic, we’re all encouraged to do things outside, and New York City is probably the worst place in the country for outdoor socializing since very few people have yards. So if you had the means, it was just more pleasant to relocate. Genetic analysis shows it was this outward flight from New York that seeded the larger national outbreak. But back in late March when people were leaving the city and the epidemic was still largely NYC-centric, all that happened was people were given vague recommendations to self-isolate for 14 days if they went somewhere new.

And there was (and has been) no real support anywhere for enforceable quarantine measures.

I drove with my family to Maine over the summer, where my father owns a house. Maine had a rule, on paper, requiring people to quarantine until they got a negative test result, which we voluntarily complied with. But there was no enforcement, and the lack of enforcement was quite open and evident. What Maine did do for a while that was much harsher than most American states was restrict hotels and short-term rentals. That served to greatly reduce the normal flow of summer tourists. But even though these half-measures did succeed in somewhat sheltering Maine from the pandemic, they proved very controversial in the state because of the economic cost.

Certainly nobody in Maine politics argued that Janet Mills should make the quarantine rules stricter.

And more broadly, while there has been a ton of left-of-center commentary arguing that the federal government could ameliorate some of these tradeoffs by doing a bar/restaurant bailout and making them close indoor dining, nobody has argued for putting real teeth on domestic travel restrictions. Many states maintain these notional lists of hotspots people aren’t supposed to travel from, but nothing is enforced. And because the United States doesn’t have any centralized quarantine facilities at all, you certainly can’t make travelers go to one.

What if?

By mid-February, I was still focused on the Democratic primary rather than the pandemic But I’d decided coronavirus would probably become a big deal in the United States. I did not have any considered policy view as to what we should do at that time, but my guess was that if an epidemic did start sweeping around America that Trump would order very harsh measures along the lines of what I’d read about in China and I started stockpiling supplies in advance of an anticipated true lockdown that never really arrived.

Instead, Trump eventually turned out to be one of the most loosey-goosey figures in American politics with regard to the pandemic. And the idea of putting restrictions on what people could do became associated with liberals. And while liberal politicians did various things, they never really tried to restrict anyone’s movement.

A fascinating document from the early days of the US pandemic response is Ian Milhiser’s March 10 Vox article, “Your legal rights in a quarantine, explained.”

It’s a good piece and it explains quarantine law and the vagueness around it well. But what’s interesting in retrospect is the framing of the piece, which sort of assumes that Vox is on your side against a government that is being perhaps more restrictive than it should be. And it’s absolutely true that if you’d asked me in 2019 to bet, I’d have said Trump was more likely to overreact than underreact to a pandemic. And I always wonder what the reaction would have been had Trump been more comprehensive in his initial China ban, closed the border entirely when it was clear the virus was in many countries, and tried to quarantine the tri-state area in a real way in hopes of controlling the smaller outbreaks elsewhere.

My guess is he’d have taken a ton of heat for it initially, but then it would’ve worked and he’d have ended up looking vindicated like Australian PM Scott Morrison — another Anglophone right-winger from broadly the same political tradition as Trump. Of course this didn’t end up happening because Trump didn’t competently take these measures we now know to be smart. But I do think one upshot of the Covid-19 experience is that the next time a new respiratory disease emerges, we ought to be much more bullish on travel restrictions.