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Comment by hga | Hacker News Reader

No: if your passport includes a stamp from the 3 affected countries (no doubt later to be expanded), you don't get in, period. Or you go straight into isolation for 21 days.

Our non-existent southern border is a further problem, mitigated to a degree by the extra time it takes to travel that way. Not to mention that if we're concerned, Mexico should be bat shit scared of Ebola breaking out in its various slums; they have little more chance of containing it in them than these three West African nations.

A little bit of research into what everyone used to when we had widespread, often endemic incurable diseases running rampant, will show that we have solutions to Ebola.

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Are there a lot of social connections between West Africa and Mexican slums? Is travel from West Africa to poor areas of Mexico something the world should actually be concerned about? Why?

(I think it is likely pragmatic to at least encourage people to not travel, for instance, I don't see why the nurse flew to Ohio in the first place, but I don't understand how the Liberia, Sierra Leone, Guinea->Mexican slum is a useful idea to focus on)

That's what I was intentionally thinking.

But then I realized it might take only one index case to start another hell on earth like we see in the three current epidemic nations.

So then you e.g. wonder about indirect vectors. Suppose, for example, those guys who pressure washed Duncan's vomit etc. outside his apartment without using any PPE, even had their water bottles too close, were directed to do it quickly, before a few days of heat and UV almost certainly killed the Ebola in it. And then one takes a visit back home.

Or look at this 2nd nurse, who felt compelled to travel to Cleveland to continue organizing her wedding. Suppose that was south of the border instead (essentially no further by air, right?).

Concepts like requiring "a lot" are potentially lethal when the real metric is "it only takes one". Not that Mexico's medical system is non-existent or hopeless by any means, I'd assume it would take another goof for it to get into an area where containment was impractical to impossible.

My general point is that as long as we (the world at large, but the US has a special responsibility to our neighbors) allow unconstrained export of Ebola from its current epidemic nations, bad things are certain to happen. Look at the current Dallas nightmare. Surely, we hope, we'll do better next time. But other nations will also screw up their first cases, and plenty have less margin.

When stakes this high ... well, here's a quick list of the big 3rd World regions and populations, in billions:

  Africa: 1.111
  Latin America: 0.558
  Southeast Asia: 0.618
  South Asia: 1.591

  Total for above: 3.378

  PRC: 1.350

Just how comfortable are we with dicing with the lives of that many people?

While it's hardly inevitable, especially if we can soon develop a safe, easily manufactured and distributed vaccine, what are we going to say to our children if we let 1 billion or more people die because we're now too [fill in the blank] to implement old fashioned quarantines.

It's maybe excessively optimistic, but I think as long as the U.S. situation is limited to a small number of known, managed cases, the health care worker travel problem should more or less be solved.

I guess a middle step would be to throw a bunch of resources at making a better voluntary quarantine available to people traveling out of the affected regions (not just the self quarantine like failed with the NBC crew, set up some facilities for it).

edit: Also, unless something has again gone horribly wrong, they should be rinsing whatever disinfectant off the sidewalks, not anything directly (and it is clear enough that bleach is effective in denaturing Ebola, so obtaining effective disinfectant isn't an issue).

"I think as long as the U.S. situation is limited to a small number of known, managed cases"

How do you reconcile that with my above "[we] allow unconstrained export of Ebola from its current epidemic nations"?

According to Congresscritter Ed Royce, the US Embassies in the three afflicted nations are receiving 100 applications for visas every day. He doesn't say how many on average are getting them, there is of course some screening, but as Duncan shows an asymptotic carrier who doesn't declare close contact with an Ebola patient (for whatever reason, no need to go into the weeds there) can get through. An incubation period of as many as 21 days is a serious problem.

This current US outbreak has, so far, a R nought of 2 (1 patient infected 2), and I don't expect other hospitals including the 4 specialist ones to necessary do a whole lot better when an unheralded patient arrives at their ER. (You're know we're finally serious about it when ERs station someone in isolation gear in outside to triage patients.)

Unlike sending a known Ebola patient to one of those 4, as we've done 4 times, with 2 cases finished, I can't call cases like Duncan "known" or "managed", at least not initially.

I fully support the known -> specialist hospital cases, if for no other reason than that we desperately need to learn more about EVD. But the random importation cases ... how can you be sure future ones will be qualitatively less of a nightmare like Dallas (which played out yet). E.g. I read someone mentioning how fortunate it was these two nurses are single and (appear to?) live alone. Imagine one having children and transmitting it to one or more of them ... that'll get ugly in a lot of ways.

And in the meanwhile the authorities continue to shred their credibility and legitimacy. Which we may not be able to afford if it gets really bad.

Ah, I didn't really answer your 2nd proposal. Why not a formal, enforced quarantine? It's not like that's required to be a terrible thing in this era of the Internet: put in the room a computer with a fast connection, a flat screen TV with a good package, and a cell phone (or more likely cell phone charger) and they should be OK until the watch period is over.

Today's medical social distancing doesn't have to be severe in the directly social sense.

I don't agree with your premise that travel is unconstrained, especially air travel (I don't have a terrific understanding of the land borders, but they are fairly long and I guess much of it is wild, completely eliminating travel across them seems impossible).

The first limit on travel is that a large portion of the population in the outbreak countries can't afford air travel. Then there is the Visa system. Then there is screening prior to boarding the flights. There is proof that this system is not 100% effective, but I don't take it as obvious that 100% effective is an attainable standard.

Who gives a damn about an 100% effective system?

Perfect is the enemy of "good enough", or in this case significantly better.

Worse, it's pretty clear that too many cases in the US will use up various finite resources, from those 23 beds really able to handle this well, to healthcare workers outside of them willing to work on Ebola patients, unless future outbreaks turn out a lot better, to PPE supplies. Not to mention the extreme expense of dealing with each patient added to already financially strained hospitals, who's ability to provide services once an Ebola patient shows up gets degraded (is the Dallas hospital ER back in operation?)

There's going to be leakers. The idea is to minimize them, and the human and economic costs they impose on us.

I didn't mean to imply that Duncan was a known or managed case (it ended up in a managed state, it didn't start there), I was describing the situation today, where the patients are admitted for appropriate care and high quality contract tracing has been done.

Anyway, as I said to you a few days ago, unless you are at least willing to revisit this in a few months or a year and consider whether the system in place was "good enough", rather than us getting lucky, there isn't much more to discuss (yes, I'm implying that my read is that you would maybe dismiss a positive outcome as luck; I don't mean to do so sneakily, nor do I intend it as an attack).

I'm at least ambivalent about whether the U.S. is prepared for the situation, the repeated mishandling of things in Dallas was not encouraging.

Oh, I'll most certainly revisit this later.

I didn't reply to your question 8 days ago in part because at this point I simply cannot envision only ~2 deaths in America (not counting the medevaced from a hotspot, 4 patients so far).

But this is fantastically path dependent. I think we discussed that just before news of Duncan's death was released; in strict terms of impact on foreign importation, that obviously decreased "Ebola tourism".

Not that Duncan, or Nigeria's index case were precisely examples of that; I've just started reading Camus' 1948 The Plague because at every level in these situations a lot of human behavior seems to be universal.

Moving on, suppose the 2 nurses who who were infected by Duncan die, that'll change things in directions making it less likely others will die in the future (for the most part; there are results that could increase the death rate). We don't yet know if Dallas missed a contact who contracts it. And I can't imagine we won't get more Duncans until a travel ban significantly cuts the potential of them.

Unless, of course, we don't get any more Duncans, in which your hope likely becomes true and we don't implement a travel ban. But I don't think that's the way to bet right now.

I don't understand what Ebola tourism is supposed to be. Are you talking about aid workers? Expats looking to leave the affected countries? Citizens of the effected countries looking to leave?

High minded global concern says you probably let qualified medical workers travel out of the country, because it's probably a net positive to let them in, and letting them out is sensible in that case. I guess most of those folks would already be doing sensible quarantines.

For the U.S., I don't think there is much of a legal framework for preventing expats from traveling back to the US (but maybe somebody should just make an order anyway and face the consequences later?). I think other countries tend to treat citizens similarly.

For citizens of the effected countries, if they can get a Visa to travel to another country, I don't see the majority of them waiting until after they have a likely exposure to make their travel plans. So they would leave seeking refuge, not treatment.

"Ebola tourism" is "Citizens of the effected countries looking to leave?", Mr. Duncan being the current example.

The other types ought to go into 21+ day isolation/quarantine; while the risk might be low, the consequences are grave, and enough doctors have been irresponsible that I'd like it to be mandatory. Those who already have Ebola go straight to one of our 23 beds for that, as we've done with 3 people. ADDED: Now both of the nurses are going to those, the 2nd is already at Emory, the 1st is now said to be going to the NIH in Bethesda. Leaving only Montana's 3 beds untested (they've never treated a case). This vote of no confidence in a perfectly fine major hospital for "normal" problems is telling (and another strike against our idiot CDC director), as will the lawsuits that will almost certainly bankrupt it. Who wants to be next?

As I understand it, public health law allows us to temporarily quarantine incoming expats and citizens, I'm not talking about a simple ban for them.

When you say "I don't see the majority of them" we get to one of our fundamental disagreements, going back to https://news.ycombinator.com/item?id=8464603 up in this subthread. I just don't believe it's responsible to think about this like that; in this case your language admits that a non-majority will be seeking treatment.

CORRECTION #3: It turns out the nation has only 11 "Ebola beds": the Omaha and NIH wards can only treat 1-2 and 2 patients with something this bad out of the 10 and 7 total beds they have. Which leaves 7 free at the moment.

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