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Letter to the Editor of The Financial Times

Posted on by CDC

Reposted from Letter to the Editor of The Financial Times, October 3, 2014


Sir, The Ebola epidemic is a problem not just for west Africa, but for the world. The longer the epidemic continues, the greater its economic, political and social impact. As you say in your editorial “The Ebola disaster is yet to be truly confronted” (September 26), the epidemic threatens public welfare and social stability, and had already had an impact on travel and trade to affected countries; in some instances, borders have even been closed.

This week I announced the first Ebola case diagnosed in the US. I have been asked whether we should stop travel to Liberia. The answer is no: to keep Americans and people in non-affected countries safe, we must continue to work to support efforts to stop the spread of Ebola in Liberia, Guinea and Sierra Leone. One strategy that won’t stop this epidemic is isolating affected countries or sealing borders. When countries are isolated, it is harder to get medical supplies and personnel deployed to stop the spread of Ebola. And even when governments restrict travel and trade, people in affected countries still find a way to move and it is even harder to track them systematically.

Involuntary quarantine and isolation of communities and regions within countries will also backfire. Restricting travel or trade to and from a community makes it harder to control in the isolated area, eventually putting the rest of the country at even greater risk. Isolating communities also increases people’s distrust of government, making them less likely to co-operate to help stop the spread of Ebola.

There are productive ways governments can support isolation. This includes providing services that increase patients’ chance of survival and that reduce the risk that caregivers will get infected. This breaks the chain of transmission. In parts of Liberia and Sierra Leone today, there are not enough facilities to isolate and treat patients. Efforts are under way in these countries to increase treatment unit beds rapidly, but the outbreak has continued to outpace these effects. Many communities in the affected regions have taken the initiative to safely isolate patients at the local level. Partners need to build on these efforts to support patients and their families.

During the smallpox era, in parts of Africa neighbors provided a hut, food and provisions to smallpox patients. Patients could not leave the hut until their smallpox scabs fell off (indicating that they were no longer infectious). Only smallpox survivors were allowed to enter the hut. This is the type of community innovation that could help stop Ebola today.

At the United Nations last week, delegates wore buttons that said: Isolate patients, not countries. The only way to stop the epidemic is to isolate and care for patients, not to quarantine entire communities, areas, or countries. Patients, communities, and countries that are fighting Ebola need our support.

Tom Frieden, MD, Director, CDC

Posted on by CDC

73 comments on “Letter to the Editor of The Financial Times”

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    This article seems to be conflating two very different issues.

    We could fairly easily ban commercial travel out of the impacted areas while simultaneously increasing our humanitarian role within the region.

    Servicemen and healthcare workers who enter the region could return home after a 21 day quarantine.

    This would allow us to aid the impacted areas and cut Ebola off at the source while also protecting the rest if the world.

    I understand that you feel that banning flights to and from West Africa is not wise, but I disagree. I do believe there should be extremely limited flights leaving from West Africa. Until a rapid Ebola testing device is developed, no one should be allowed to exit the affected countries without being quarantined first or being fully tested. If people want to leave West Africa, they should have a much more rigorous test done before boarding an outgoing flight. If it takes several days for testing, then they need to wait several days before being cleared to leave. Then upon arrival, they should be required to be retested and have to provide their plan future journey.

    Checking for a fever is not enough. I have read that travelers are taking ibruprofen to lower their temperatures so they cannot have a denied flight. Knowing this makes me very uneasy. All I can do is worry for the future of my newborn baby and hope to god stricter restrictions are set in place to control the spread of this virus. I will certainly hold the CDC responsible for the spread of Ebola if more people end up with this virus in the US. It is irresponsible for us to freely allow untested individuals into our borders from areas that are known to be hotbeds for the disease. If my child or anyone in my family ends up contracting this virus, I will blame you for not doing enough. It is fine that people want to go to West Africa to help, and it is fine for people to send supplies, but there should be a definite restriction on the people who plan to leave the region. It is common sense. Testing should be required on all individuals leaving the region. The cost of the testing, should be a part of the flight price. I know that I am not the only one who feels this way.

    There is a growing trend of people online, who believe this entire epidemic is being led by the pharmaceutical companies. I don’t believe this yet, but if the CDC keeps telling us air travel shouldn’t be controlled, I may begin to believe it. Some people feel the CDC has no idea what to do and everything you say is a lie. There may be some truth to this. But, what would help calm people? It would be for the US government to do something wise and strong; show that we are actually protected. Instead, we feel we are being told lies. Our families and friends, want to feel safe. Allowing air travel to and from West Africa without strict guidelines, is the wrong thing to do. It scares us and leads us to believe we are worthless. As a health professional myself, I want to know that I work for a system that chooses to protect me so I can continue to care for my family. Currently, I don’t feel the CDC has my interests protected nor do they for the rest of the nation.

    And what about animals in the US? There isn’t a lot known about whether Ebola can transmit to animals in the US, but now that Ebola has entered the US, what will happen if it can spread to a common animal, such as pigs? Or the common bat? And how will Ebola be contained if more people like Duncan board planes and enter the US? Americans do much more commuting, travel, eating out, and shopping in wide areas, than people in West Africa. If a person who becomes infected with Ebola, works in a restaurant, goes to work feeling ill, but carries on anyway, serves food and drinks with their sweaty hands, how many more will be infected? Many times sick individuals continue to work, because that is what has become expected in our society, unfortunately. Perhaps the president or the CDC should make a national announcement, making people more aware of what to be cautious of. Not cause panic, or insight violence against Africans, but to be aware of how the disease spreads and that people should be very vigilant about cleaning hands.?? That’s my 2 cents!.

    Ebola is not going to be stopped by aid workers coming in from abroad. They will only get sick and spread the disease. The key is to make systematic use of the key resource that is unique to the hot-zone countries: immune survivors.

    By paying immune survivors to administer the isolation and care of infected and possibly infected individuals it would be possible to create a “negative atmospheric pressure,” where it is safer for uninfected individuals to stay in the hot zone rather than to try to flee. People have a strong inclination to stay where their life is already established and travel is itself a high risk factor for contagion so if the hot zones can be made reasonably safe by hiring survivors to isolate and tend the sick then people will want to stay put. The “atmospheric pressure” will not be expulsive but will be inwards, keeping the possibly infected population contained.

    Aid workers from outside cannot perform this role. They will get sick. Only immune survivors can stop the disease from transmitting, which brings us to Dr. Friedan’s egregious claim that: “When countries are isolated, it is harder to get medical supplies and personnel deployed to stop the spread of Ebola.”

    Holy cow dude. First, any travel that the United States sets up can include whatever exemptions for medical supplies and personnel that are deemed appropriate. For the guy whose job is to make the rules it’s bizarre to hear you claim that you can’t restrict travel out without also blocking assistance.

    But more basically, it is a huge mistake to be sending more than a few people in anyway. We should be sending in enough to set up training for the immune survivors and to oversee logistics and that’s it. That is ALL the people we should have in the hot zone. Certainly there should not be any U.S. troops.

    Friedan is also against travel restrictions because, as he says: “people in affected countries still find a way to move and it is even harder to track them systematically.” Obviously it is better to reduce the incentive people have to flee in the first place by reducing and stopping local transmission of disease, but this claim that restrictions actually increase the outward movement of the disease is groundless. Each nation can and should protect itself by being very careful that no infected people care allowed to cross its borders, and if all nations to this, that is a very good thing. It will stop the spread of Ebola.

    Friedan assumes a “citizen of the world” pose where he seems to feel revulsion for the idea of protecting one’s own country. Sorry but this is not a higher morality. It is a perverse failure of basic morality. If every nation thinks first of protecting its own then transmission will be greatly contained. This is the FIRST imperative, and it calls for immediate and severe restrictions on travel to the United States by anyone who has recently been in West Africa.

    By all means also try to organize an effective contagion-ending response within the hot-zone nations, but the only effective such mechanism relies almost entirely on a purely native resource: the growing number of immune survivors. Aid workers should NOT be going there. Teleconference the training in, and drop off supplies. We need almost no one in-country.

    If anyone wants to see more on the dynamics of “negative atmospheric pressure,” I put up a post on the subject a few weeks ago:

    First Ebola transmission in a non-African country has just been confirmed: a spanish health-care worker who assisted 2 Ebola infected patients who were transfered from African countries to Spain. According to Spanish Health Department this health-care worker started fever and other sympthoms on the 30th September, but did not fullfill CDC case definition until 6th October (fever was under 38.6 as CDC definition limit). No isolation was started, so during 6 days, potential new transmission events may have ocurred. Is CDC going to review case definition criteria according to this case in Spain? Luis Escosa-García MD. Madrid, Spain.

    We are in the process of updating our screening criteria. The new temperature for screening will be 100.4°F (38°C). The temperature for the case definition will remain the same.

    “Dr.” Frieden, you are a liar. Not a very good one either. Saw you on Cavuto yesterday. You actually believe the nonsense you are espousing on not having a travel ban? The US is screwed because of your insane, unsupported logic. Then again one should not expect anything less from one of thing called obama minion’s.

    FTA: Concern for “what people think” should not be such a great priority for Dr. Frieden, unless politics be his true bailiwick. It is not certain where Dr. Frieden’s priorities lay. It seems clear that he should be duty bound to our country and its inhabitants. That might be a point debated by Dr. Frieden. Self assumed global duties seem his top priority…….Dr. Frieden should be duty bound to this nation first, to the eradication of disease in other countries and world community concerns, second.”

    I agree.

    This runs all over me. And, it should completely shred any credibility Frieden has left. The phrase “sealing the border” implies not letting anyone in or out. And, no one has called for that. What most Americans are asking on this matter is that travel into and out of the affected countries be stopped. That is only reasonable and prudent. And, that is a far cry from “sealing the borders.” Once again, we have our language being hijacked by the left. This time by a regime spokesman who needs to simply go away. Now.

    Then why quarantine anyone, anywhere, anytime? Stopping travel from ebola countries is just a larger quarantine. Your logic makes no sence whatsoever. I must conclude that you are just another politcally correct government front man for Obama. The next time I get the flu or a cold, I won’t bother to stay at home because you said stopping travel won’t stop the spread of a disease.

    I wonder what they did when they had diptheria or other epidemics? They quarantined those who were sick, the whole household, not just one person, because of the fear of spreading the disease, until it was over. We cannot allow people from that ‘household’ to be around those who are well. It will spread the disease until we are ALL dead. Use common sense, not worry about being ‘politically’ correct, which is a crock to begin with!

    The facts currently are:
    (1) We are sending soldiers, therefore they are most likely not going via American Airlines but by military transport.

    (2) Our military has one of the best logistical capabilities of any major organizations of the planet, military or civilian.

    So the argument about logistics going south because of a ban on civilian transport is so demonstrably false as to be laughable. The military can easily arrange for any additional supplies or trained personnel to be airlifted in, by the most trained and capable logistics people in the world, as needed.

    (3) The local governments and their people are NOT the first and over riding concern or the American Government. Those entities did not elect them, the American people did! The primary duty of that government, as stipulated in their oaths of office, is the immediate safety and well being of those citizens.

    If a visa halt from those Ebola ravaged nations upsets those nations and their populations, so be it.
    If all nations flying airlines were to cooperate in a visa quarantine, there is no reason to believe it would not be effective.
    Given the relative rapidity of this disease, any potential border jumpers would be sick or dead before they made it to the America`s, let alone the US border.

    Political correctness is a poor substitute for REAL science.

    After all, we do have potentially enforceable borders, so perhaps if some of those troops were also allocated to protect them, we would not need to worry about undocumented travel into the USA by anyone who was infected by Ebola, or for that matter, Enterovirus, TB, Scabies, Leprosy, or any of the other third world diseases this nation has had to contend with lately.

    But in closing, Sir, your arguments simply DO NOT justify violation of the long established and primary rule of epidemiology which is Isolation AND QUARRANTINE.
    As a college educated and trained medical sciences professional, you SHOULD know that, but I guess PC politics tends to blind even science professionals.

    So, sealing the borders of a nation, which is at risk of a pandemic, for a virus which is NOT fully understood & has begun to mutate, will make people “not trust the government”?

    I’ve got news for you, Pal… We already DO NOT trust the federal government! Why would we trust a government (including the CDC) which intentionally brings infected people into the country, with a deadly virus?

    We are seeing firsthand, here in North Texas, that “YES” you can contract Ebola (probably through airborne transmission) as there are now multiple patients, here. Add to that, the fact that even the WHO is warning that the virus is able to be spread via airborne transmission, and has now spread to Europe.

    CDC has been WRONG at every step of the way in the total mismanagement of this infection!

    And, THAT, Sir, is just one example of why the American people do NOT trust the federal government!

    I wonder how much money this Tom Frieden is getting from the drug companies and the Government to set us up with this and lie to us because we all know he is a liar.

    I just wrote a piece on this very topic

    In that article I mentioned an idea I had, that the US could set up CDC-staffed quarantine stations at every airport in West African countries hit by the virus. We can send aid workers, military personnel and other essential persons over but…when they come back they have to stay in quarantine for the 21-day incubation period.

    As to individuals like college students on Visa and others who MUST return here, everyone must be quarantined first.

    SOS International published a list of countries, most of which are in Africa, who have banned or severely restricted travel from West Africa. If they can do this, why can’t we? And when we do it, we need to encourage other nations to do the same.

    Director, you imply that placing travel restrictions would impede the ability of essential persons to travel back and forth. No, it would not, it would add annoyances and time to their trip but isn’t it worth it if it saves lives?

    But of all the ridiculous statements I have read from the government and CDC so far, THIS one takes the cake:

    “Isolating communities also increases people’s distrust of government, making them less likely to co-operate to help stop the spread of Ebola.”

    This shows just how out of touch you all are with the American people. We WANT to help the people in Africa. But when you give us such ridiculous excuses why you cannot take more preventive measures, when you put politics before common sense…that’s what makes us distrust you. Right now we are being tested. Now, it’s Ebola, but later it could be something else. This is NOT a test we can afford to fail.

    The head of the CDC is a total idiot. Screening people comming off of aircraft does nothing. If they have any symptoms then you would have to detain everyone on that flight. The common sense thing to do would be to ban all flights in and out of that area as other countries have done. The CDC has no idea how this virus can or has mutated. This virus has the capacity to spread and multiply in numbers they would not be able to handle. This administration and their cronies like the head of the cdc will be the death of us all.

    This seems to contradict your motto of “protecting the people and saving lives”. The first step is isolation and quarantine. It’s very simple. We restrict all travel out of the affected areas until this epidemic is contained. That is not to say that we cannot continue to allow medical aid and supplies to be flown in but ALL commercial flights need to be stopped. We don’t care about the governments of these foreign countries or the unrest of the people!! If this virus isn’t stopped there will BE NO PEOPLE or government left. To continue to allow people to freely fly into the US and Europe and Canada is just plain dumb. I don’t need a PhD. to figure that out. PLEASE start protecting the people & worry about the politics later!

    Dr. Tom Frieden,

    I would like to remind you of the CDC Mission Statement.

    CDC works 24/7 to protect America from health, safety and security threats, both foreign and in the U.S. Whether diseases start at home or abroad, are chronic or acute, curable or preventable, human error or deliberate attack, CDC fights disease and supports communities and citizens to do the same.

    CDC increases the health security of our nation. As the nation’s health protection agency, CDC saves lives and protects people from health threats. To accomplish our mission, CDC conducts critical science and provides health information that protects our nation against expensive and dangerous health threats, and responds when these arise.

    Your recent statements arguing against a travel ban on West Africa defies logic, and rises to the point of being reckless. Each death in the US from this date forward is on your hands, and when this is over you will be judge for actions.

    Reckless endangerment is a crime consisting of acts that create a substantial risk of serious physical injury to another person. The accused person isn’t required to intend the resulting or potential harm, but must have acted in a way that showed a disregard for the foreseeable consequences of the actions.


    The only logical solution to preventing the spread of Ebola into the US is to halt travel of NON-US CITIZENS from Ebola outbreak areas. Low cost, easy peasy fix: just put a moratorium on issuing visas to would be travelers from Liberia, Sierra Leone, and Guinea until the outbreak is over. Is it enough? No. Is it 100%? No. Is it a necessary piece? YES!

    If there is a absolute necessity for a visitor from an Ebola area to come to the U.S., require that they be quarantined or don protective gear 24/7 for 21 days – at their own expense!

    It has been suggested that the reason we haven’t had more cases like the one in Dallas is the backlog of visa applications in at least two of the countries listed above. By the time the visa is granted, many of the applicants have already died. Unless the delay is the surreptitious way the administration is making an end run around its own policy, I just can’t understand why a travel ban has not yet been been put in place.

    As a learned man of apparently above average intelligence, I similarly fail to understand how you could conclude that a travel ban isn’t needed or would somehow be counterproductive. I am left with only one conclusion: you are a tool!! I just can’t figure out who you are a tool for!

    The United States Army Medical Research Institute of Infectious Diseases conducted a monkey to monkey Ebola study in December 1995, published in The Lancet, Vol. 346. (Here is a link to the abstract, but the entire article must be purchased.) http://www.ncbi.nlm.nihdotGOV/pubmed/8551825

    “Several Rhesus monkeys were infected with Zaire Ebola by intramuscular injection while three control Rhesus monkeys were kept in cages separated 10 feet from the infected monkeys. All of the injected monkeys died of Ebola by day 13 and 2 out of 3 control monkeys died of Ebola by 8 days after that. The authors of this study concluded that:
”The exact mode of transmission to the control monkeys cannot be absolutely determined, although the pattern of pulmonary antigen staining in one of the control monkeys was virtually identical to that reported in experimental Ebola virus aerosol infection in rhesus monkeys, suggesting airborne transmission of the disease via infectious droplets… Fomite or contact droplet transmission of the virus between cages was considered unlikely. Standard procedures in our BL4 containment laboratories have always been successful in the prevention of transmission of Ebola or Marburg virus to uninflected animals. Thus, pulmonary, nasopharyngeal, oral, or conjunctival exposure to airborne droplets of the virus had to be considered as the most likely mode of infection… Our present findings emphasize the advisability of at-risk personnel employing precautions to safeguard against ocular, oral, and nasopharyngeal exposure to the virus.”

    More recently (this month), Dr. Brantly acquired Ebola while strictly following CDC guidelines (simple mask, goggles, or face shield, gloves, gown, leg covering, shoe covers), so it is likely he became infected by inhaling contaminated droplet nuclei into his lungs or having them settle into his conjunctival (eye) sacs despite the use of CDC level protection against direct contact. Dr. Brantly apparently did not use a full-face respirator with P-100 filters, but rather a simple or N-95 face mask. An interviewer noted that
    “Brantly says he isn’t sure how he got infected. He’s certain he didn’t violate any [CDC] safety guidelines.”

    Now do we understand WHY the borders must be closed? This can be done WHILE still allowing INBOUND medical supplies and OUTBOUND flights to relieve medical workers ?

    Sorry for all the supper case.

    The protocol for contact tracing should call for the immediate test and quaratine all identified persons who came in contact with the symptomatic patient. The current protocol leaves a hole in the timeline where patients, who are bordering on symptomatic, will still potentially come in contact and infect others.

    Please correct me if I am mistaken.

    Tom Frieden and his CDC stumblebums have been recklessly cavalier. Every STEP of the way, they have been reactive rather than proactive. They obviously care more about looking good than caring about the safety of the American People (especially their health care workers!). It is obvious we come DEAD LAST.
    You are letting these people in KNOWING that the virus will not (cannot!) be contained with the current means at our disposal. You have flagrantly VIOLATED the 1st LAW of Epidemiology…which is you CONTAIN by ISOLATION. You have any doubts, you DON’T take chances! Now you’re backpedaling, and doing damage control AFTER the fact. CLEARLY you DON’T have a handle on it, CLEARLY you did NOT think this thru, CLEARLY this is OUT of CONTROL. Resign NOW.

    Tom Frieden: It is incredibly irresponsible to bring ebola patients into a country without the disease and risk further spreading it world-wide. I’ve read this article and your justification is absurd. I think CDC Director Tom Frieden should reconsider his stance in light of the 26-year-old nurse who has contracted the virus and the risk the CDC has chosen to put hospitals, their workers, patients, and general public at risk for this disease. I think blaming the nurse for a breach in protocol is another way of protecting the powers allowing this disease to enter the US. When is going to end? And, will Frieden and his employers be held responsible for the deaths of all the innocent people in this country who contract this illness from people coming back from Africa? I think not. It’s time someone went over Frieden’s head and made decisions that will stop the spread of this illness before it’s too late.

    As a registered nurse, I am extremely concerned about the perceived lack of Government leadership and preventative measures to safeguard the citizens of our country from acquiring Ebola infections. Furthermore, it is important to understand that many U.S. hospital nurses and physicians are not adequately prepared to provide standardized and optimal infection prevention precautions, isolation containment, and treatment for patients infected with the unforgiving Ebola virus. Health care professionals are faced with navigating unchartered territory related to effectively treating Ebola patients, which is a daunting task. To avoid or minimize a preventable life threatening Ebola epidemic in our country, please impose immediate travel restrictions on airline passengers from affected areas in Africa. Thank you for considering this urgent request.

    Lets get real. Innocent United States residents will needlessly DIE unless there is an enforceable travel ban to and from the effected West African nations.
    A united world coalition of health care providers then can set up “medical shop” in these countries in order to isolate and eradicate the virus.
    Pharmaceutical companies should be given appropriate “perks” by their respective governments in order to develop and implement an effective anti-viral agent (s) and or vaccine. A united world coalition should then assess the present socio-economic conditions and implement positive intervention strategies with the respective governments to minimize the probability of a re-occurence of this infectious killer virus. After the virus is either been de-natured or killed and after the
    infected populations are been isolated for medical management and the living conditions have been improved, then and only then should this nation consider permitting travelers into this country after they all have been infection-free for a 21 day period under enforceable and verifiable quarantine. If this is not immediately implemented, I believe that the United States government will be responsible for
    the murder of innocent United States residents. Doctors and Bureaucrats at the CDC please take immediate, emergency, affirmative action! Thank you.
    Donald P. Milione, D.C.

    Dr. Frieden, I don’t know how you have managed to remain civil and professional in the face of some of the insanity you have been subjected to, but somehow you have. Please continue to be the voice of sanity in a sea of hysteria. Thanks so much for your service.

    It sounds like Dr. F is more worried about those African countries than he is about the the people who pay his salary, i.e. the citizens of the USA.

    Has Obama given him his orders to behave in such an outrageous fashion? All my ancestors spent time in quarantine when they came to America. They did that for the safety of the people already living here. Why are travellers from Africa treated better today? Especially given the risk they pose.

    Time to rediscover the wisdom of those times, and put people who show any symptoms of Ebola into quarantine BEFORE they get on the aircraft that will take them here.

    Anything less is simple idiocy.

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