Controlling COVID-19: The Folly of International Travel Restrictions
Weijun Yu and Jessica Keralis
The global public health community is grappling with COVID-2019, a respiratory disease outbreak caused by a novel coronavirus originating from Wuhan, China in late December 2019.[1] A number of countries implemented citizenship-based travel restrictions in late January and early February as an initial response to the outbreak, barring entry to foreign nationals who had previously been in China to prevent the importation of the virus.[2] By early March, when the World Health Organization (WHO) formally declared the outbreak to be a global pandemic, these countries were still relying on travel restrictions as a means of infection control. These travel restrictions constituted restrictions or outright bans on the entry of foreign nationals with a particular citizenship-such policies tend to be popular with a general public with limited public health knowledge.[3] However, travel restrictions are ineffective as an infection control measure and may do more harm than good, depriving the public of its right to health.[4] Furthermore, travel restrictions implemented under the guise of public health policy have historically been used to target migrants and racial and ethnic minorities, violating their rights to non-discrimination and equal treatment.[5] As states rush to balance public health with politics in their response to this global pandemic, they are sidelining human rights rather than protecting them.
Ineffective epidemic control strategies deny the health rights
Travel restrictions as a disease control strategy have a long history and are attractive to policymakers as a means of calming public anxiety toward foreign contagion.[6] Despite alleviating fear and panic among the public, they are not an effective approach to containing the spread of epidemics (Figure 1). Indeed, in its February 28 situation report, WHO explicitly discouraged the use of any trade or travel restrictions to control the COVID-19 outbreak.[7] While most modeling studies have been in agreement that strict travel restrictions in theory delayed the spread of the epidemic, the estimated delays were minor (a few days to a few weeks, depending on the simulation), and some scientists have raised the question of whether they are worth the human and economic cost.[8] Although one analysis estimated that China’s internal travel restrictions slowed the export of SARS-CoV-2 infections and delayed the spread of the outbreak to unaffected cities, another found that the lockdown of Wuhan only delayed the domestic epidemic in China by 3-5 days.[9] Similarly, Anzai et al. found that the impact of travel reductions from the lockdown in China delayed the Japanese epidemic by only two days.[10]
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Potential COVID-19 cases can be any individuals with any citizenship, with travel history to countries outside China, or none at all. The outbreak in Iran, one of the largest outbreaks outside China, underscores the futility of citizenship-based travel restrictions: according to the Iranian health minister, the source of the epidemic was an Iranian national who circumvented the country’s travel restrictions by using indirect flights.[11] In South Korea, which saw the largest outbreak outside China by the end of February, less than 1% of confirmed cases were exposed in China, with many of the country’s confirmed cases linked to large religious gatherings in Daegu and Gyeonggi Provinces.[12] The current outbreaks in Italy, Spain, Germany, and Switzerland also started with very limited imported cases from China.[13] For example, Spain’s first confirmed case was a German national, and most of its initial cases were Italian citizens or Spanish nationals who were exposed in Italy.[14] These ineffective restrictions can also worsen the spread of the virus by lulling the public into a false sense of security, preventing authorities from being able to effectively contain the spread of the virus at the early stages of the epidemic by diminishing the urgency of health messages promoting effective measures such as frequent hand washing and social distancing.[15]
Travel restrictions as a pretext for discrimination
The travel restrictions toward China, as well as restrictions targeting foreign nationals with travel history to South Korea, Iran, and several European countries, are still in place in some countries even as they grapple with their own domestic outbreaks. Implementing coercive travel restrictions against other countries not only violates international law but also jeopardizes efficient global cooperation.[16] There is evidence that travel restrictions, under the guise of public health policy, have been used by some governments to discriminate against resident Chinese citizens.[17]
Similarly, the Cambodian government has banned individuals from Italy, Germany, Spain, France, and the United States from entering and specifically identified Cambodian Muslims as having tested positive for coronavirus, sparking online and in-person harassment of Cambodian Muslim minorities.[18] These policies may also encourage or reinforce stigma against Chinese citizens, individuals of Asian ethnicities, and ethnic minorities, similar to what was seen during the Ebola outbreak in 2014.[19] For example, there is growing concern that Asians in the United States are experiencing more racist verbal and physical attacks as a result of the racially charged rhetoric that has been used by public officials when discussing the epidemic.[20] Additionally, the ongoing international travel restrictions in some countries may be discouraging migrants without health insurance from seeking necessary testing and treatment.[21]
Evidence-based epidemic control strategies protect public health and human rights
Travel restrictions violate international law. Although global health and human rights law in some circumstances permits restrictions of rights for the purposes of protecting public health, such measures must be the least intrusive means available of doing so.[22] Given that travel restrictions have not been effective historically, and that there is evidence that they are counterproductive in this epidemic as in previous ones, it is apparent that they do not meet the criteria outlined by the International Health Regulations that are binding on all WHO member states.[23]
The United Nations has urged countries to maintain human rights “without exception” as they fight the COVID-19 pandemic.[24] The global health community has spent decades implementing evidence-based strategies to contain the spread of disease and protect the public’s health without violating human rights. WHO also developed specific guidance for countries affected by the SARS-CoV-2 epidemic in the early stages of the global outbreak.[25] These, and effective messaging to educate and inform the public, are the most effective tools to protect public health while safeguarding the human rights of individuals of all citizenships.
Weijun Yu, MD, MSc, and Jessica Keralis, MPH, are PhD students in epidemiology with Department of Epidemiology and Biostatistics, School of Public Health, University of Maryland, College Park, MD, USA.
References
[3] B. K. Wagner and M. Van Volkenburg, “HIV/AIDS Tests as a Proxy for Racial Discrimination-A Preliminary Investigation of South Korea’s Policy of Mandatory In-Country HIV/AIDS Tests for Its Foreign English Teachers,” Journal of Korean Law 11 (2011), p. 179; S. Hensley, “Poll: Broad Support In U.S. For Ebola Travel Ban,” NPR (October 22, 2014). Available at https://www.npr.org/sections/health-shots/2014/10/22/358095163/poll-broad-support-in-u-s-for-ebola-travel-ban.
[4] A. L. P. Mateus, H. E. Otete, C. R. Beck, et al., “Effectiveness of travel restrictions in the rapid containment of human influenza: a systematic review,” Bulletin of the World Health Organization 92/12 (2014), pp. 868-880D; Chang, H. Prytherch, R. C. Nesbitt, and A. Wilder-Smith, “HIV-related travel restrictions: Trends and country characteristics,” Global Health Action 6 (2013), 10.3402/gha.v6i0.20472; N. A. Errett, L. M. Sauer, and L. Rutkow, “An integrative review of the limited evidence on international travel bans as an emerging infectious disease disaster control measure,” Journal of Emergency Management 18/1 (2020), pp. 7-14; J. M. Keralis, “At the Nexus: How HIV-Related Immigration Policies Affect Foreign Nationals and Citizens in South Korea,” Health and Human Rights 19/2 (2017), pp. 123-132.
[9] C. R. Wells, P. Sah, S. M. Moghadas, et al., “Impact of international travel and border control measures on the global spread of the novel 2019 coronavirus outbreak,” PNAS 117/13 (2020), 10.1073/pnas.2002616117; M. Chinazzi, J. T. Davis, M. Ajelli, et al., “The effect of travel restrictions on the spread of the 2019 novel coronavirus (COVID-19) outbreak,” Science (2020), 10.1126/science.aba9757.
[12] S. H. Choe, “Shadowy Church Is at Center of Coronavirus Outbreak in South Korea,” New York Times (February 21, 2020). Available at https://www.nytimes.com/2020/02/21/world/asia/south-korea-coronavirus-shincheonji.html; C. K. Park, “Coronavirus: saltwater spray infects 46 church-goers in South Korea,” South China Morning Post (March 16, 2020). Available at https://www.scmp.com/week-asia/health-environment/article/3075421/coronavirus-salt-water-spray-infects-46-church-goers.
[[14]] P. Linde, “Sanidad confirma en La Gomera el primer caso de coronavirus en España,” El País (February 1, 2020). Available at https://elpais.com/sociedad/2020/01/31/actualidad/1580509404_469734.html; J. Sanchis, “Sanidad confirma seis nuevos casos de coronavirus en la provincia de Valencia,” Las Provincias (February 27, 2020). Available at https://www.lasprovincias.es/comunitat/sanidad-confirma-nuevo-20200227090714-nt.html.
[15] Global Commission on HIV and the Law, Risks, rights, and health (New York: UNDP, July 2012); M. Thielking and L. Facher, “Health experts warn China travel ban will hinder coronavirus response,” STAT News (January 31, 2020). Available at https://www.statnews.com/2020/01/31/as-far-right-calls-for-china-travel-ban-health-experts-warn-coronavirus-response-would-suffer/.
[17] T. Yang, “Russia may become first country to deport Chinese nationals in response to coronavirus,” Los Angeles Times (February 28, 2020). Available at https://www.latimes.com/world-nation/story/2020-02-28/russian-entry-ban-on-chinese-nationals-has-some-seeing-red; Reuters, “Kazakh governor to seek deportation of Chinese over coronavirus fears” (February 20, 2020), Available at https://www.reuters.com/article/us-china-health-kazakhstan/kazakh-governor-to-seek-deportation-of-chinese-over-coronavirus-fears-idUSKBN20E2KA.
[19] L. Lin, B. J. Hall, L. C. Khoe, and A. B. Bodomo, “Ebola outbreak: from the perspective of African migrants in China,” American Journal of Public Health 105/5 (2015), p. e5; J. Sanburn, “Ebola Brings Another Fear: Xenophobia,” Time (October 29, 2014). Available at https://time.com/3544130/ebola-panic-xenophobia/.
[20] K. Phillips, K., “‘They look at me and think I’m some kind of virus’: What it’s like to be Asian during the coronavirus pandemic,” USA Today (March 28, 2020). Available at https://www.usatoday.com/story/news/nation/2020/03/28/coronavirus-racism-asian-americans-report-fear-harassment-violence/2903745001/; S. Tavernise and R. A. Oppel, “Spit On, Yelled At, Attacked: Chinese-Americans Fear for Their Safety,” New York Times (March 23, 2020). Available at https://www.nytimes.com/2020/03/23/us/chinese-coronavirus-racist-attacks.html; L. Aratani, “‘Coughing while Asian’: living in fear as racism feeds off coronavirus panic,” Guardian (March 24, 2020). Available at https://www.theguardian.com/world/2020/mar/24/coronavirus-us-asian-americans-racism.
[21] M. Jordan, “‘We’re Petrified’: Immigrants Afraid to Seek Medical Care for Coronavirus,” New York Times (March 18, 2020). Available at https://www.nytimes.com/2020/03/18/us/coronavirus-immigrants.html; E. Reidy, “ow the coronavirus outbreak could hit refugees and migrants,” New Humanitarian (February 27, 2020). Available at https://www.thenewhumanitarian.org/news/2020/02/27/Coronavirus-Iran-refugees-IDPs-Italy-Europe-disease.