Ebola Federalism

While the federal government plays a leading role in keeping Ebola out of the US – to the extent that it’s possible – governors have the authority to come up with their own protocols for dealing with suspected patients who arrive in their states. Josh Voorhees sees a few problems with that:

Consider the rules that greet medical workers upon their arrival at one of five federally mandated points of entry. Land in New York City or Newark, and they face a mandatory 21-day quarantine, regardless of risk level. Arrive in Chicago, and they should be prepared for the same—unless, that is, they wore “protective clothing” while treating patients. Fly into Atlanta, and they can either agree to check in twice daily with health officials or be involuntarily quarantined at a “state-designated facility.” Touch down at Dulles International in Virginia, and they face the same active monitoring but without the threat of forced isolation. …

America’s governors, meanwhile, say they are just doing their jobs. “My first responsibility is to protect the public health and safety of the people of New Jersey,” [Chris] Christie told the Today show on Tuesday. That’s exactly the problem. The fact that a governor, almost by definition, focuses first and foremost on the short-term risk to his own state leaves him unable to consider the bigger picture.

In a speech yesterday, Obama implicitly scolded Christie and other governors who have opted for extraordinary measures such as mandatory quarantines for reacting to the epidemic “based on our fear”. Gregg Gonsalves harshly criticizes these governors, whom he says “have dealt a serious blow to the credibility of the CDC and the NIH as well”:

By instituting evidence-free policies, these politicians are effectively telling the American people, “You can’t trust the folks in Atlanta or Bethesda to take care of you, and you can’t believe their version of the facts; we know better.” It is a message that is not easily forgotten. The governors’ words and actions play into a general distrust of government and a sort of scientific denialism, where each person gets to decide what the facts are. It creates confusion about which institutions Americans should listen to, and whose advice they should follow, when it comes to public health. In ignoring the expertise and mandates of the CDC and the NIH, the governors are claiming, wrongly, that the public should look closer to home for correct guidance. The risks of this situation cannot be overstated.

In an editorial in the New England Journal of Medicine, seven doctors and public health experts underscore that mandatory quarantines are unnecessary given what we know about how Ebola is transmitted, and may in fact do more harm than good:

A cynic would say that all these “facts” [about the science of Ebola transmission] are derived from observation and that it pays to be 100% safe and to isolate anyone with a remote chance of carrying the virus. What harm can that approach do besides inconveniencing a few health care workers?

We strongly disagree. Hundreds of years of experience show that to stop an epidemic of this type requires controlling it at its source. Médecins sans Frontières, the World Health Organization, the U.S. Agency for International Development (USAID), and many other organizations say we need tens of thousands of additional volunteers to control the epidemic. We are far short of that goal, so the need for workers on the ground is great. These responsible, skilled health care workers who are risking their lives to help others are also helping by stemming the epidemic at its source. If we add barriers making it harder for volunteers to return to their community, we are hurting ourselves.

Would a 21-day, at-home quarantine with state reimbursement for lost work really inhibit health workers from volunteering in West Africa? These are people who are already intending to travel across the ocean to the most virulent hot zone on the planet – but a three-week paid vacation at home is a deal-breaker? If the threat of quarantine is enough to scare health workers away from volunteering, Amy Davidson argues, West Africa is screwed:

[Kaci] Hickox spent the night before she headed home to America watching a young girl die; that is hard enough. If the prospect of three weeks in a tent in a Jersey parking lot or, God forbid, reading the works of Andrew Cuomo discourages them, the argument goes, then the disease will spread out of control in Liberia, Sierra Leone, and Guinea, more people will flee those countries, and the United States will face a far greater risk than that posed by a doctor going to a bowling alley in Williamsburg. This is practical, but it raises another question: why, exactly, is the burden being put on already overwhelmed volunteers in the first place? Can’t we do more, and more directly? What does it say about the help available to West Africa if a little bullying by Chris Christie could make it all fall apart?

Clive Crook sensibly maintains that science alone can’t answer the policy question of how best to respond to the outbreak:

You don’t have to be a cynic, a slanted term, to argue for “better safe than sorry.” The calculus isn’t simple, either. The crucial thing, though, is that the doctors’ sensible conclusion doesn’t rest solely on the science. It requires a delicate judgment about many different risks and costs — the risk of extra U.S. cases in the short run, the risk of discouraging health workers from traveling to West Africa so that the disease keeps spreading there, the cost in civil liberty of restricting people’s movements, and so on. I agree with the doctors about where the balance lies, but the issue isn’t easy and, in any event, it isn’t just about the science of Ebola.