The United States is imposing strict restrictions on American travelers who have been exposed to dual Ebola and hantavirus outbreaks, a move that experts argue could run counter to their legal rights and affect the willingness of volunteers to respond to future public health crises globally.
The latest restrictions highlight a shift in official rhetoric on public health measures and attempts to contain outbreaks, including reported opposition from the White House to allowing Americans to return home. Instead of repatriating an American doctor sickened by Ebola and six others with exposure, the patients and others are being moved to Germany and the Czech Republic, officials confirmed on Wednesday.
Alexandra Phelan, an associate professor at Johns Hopkins Bloomberg School of Public Health, warned that it is "unlikely" that there will not be more cases of US citizens and residents wishing to return from Ebola-affected regions. She added, "it would be very concerning if Americans weren't able to." The unofficial policy, she said, could substantially dampen the response from volunteers providing critical assistance in the region.
"There is a very real likelihood that this outbreak may get much more serious, and the need for international support is going to be quite significant," Phelan said.
The move follows mandatory quarantine measures in Nebraska for passengers from the MV Hondius who were exposed to Andes virus, a type of hantavirus, despite requests from some passengers to quarantine at home.
The American Ebola patient is now hospitalized in Germany in stable condition, while other US citizens were en route to Germany or Czechia, according to Satish Pillai, the Ebola response lead at the US Centers for Disease Control and Prevention (CDC). "These people, who remain asymptomatic, are being moved to ensure that they have access to the specialized care if needed," he told journalists on Wednesday.
When asked why these locations were chosen instead of evacuating the Americans home as in previous outbreaks, Pillai said they were the "most expeditious" options in a fast-changing situation with "the need to move quickly," adding that "these locations were chosen based on the needs that were present at that time." Czechia, in particular, is not known for its experience in treating viral hemorrhagic fevers, but Pillai noted it had an existing relationship with the US State Department and the Administration for Strategic Preparedness and Response.
During the 2014-15 outbreak, then-candidate Donald Trump was outspoken about Ebola, posting frequent calls on social media for Americans who had Ebola or were exposed to the virus to be turned away. "People who volunteer to help in Ebola outbreaks must suffer the consequences," he said in August 2014.
In this outbreak, the White House opposed bringing at-risk Americans home, according to reporting by the Washington Post. Pillai would not confirm this in the press conference, instead pointing to "the conditions on the ground" and "the need to rapidly mobilize."
But the law on being able to return home is "really simple," Phelan said. US citizens and green card holders have a legal right to return to the United States. The order on travel restrictions issued on Monday is clear that it does not apply to US citizens. Moreover, the US has some of the best biocontainment facilities, medical care, and treatment options in the world. "Millions of dollars have been poured into these facilities for exactly this situation," Phelan added.
Doubt about whether health workers and other outbreak responders may return to the US could mean fewer Americans volunteer to help stop the outbreak. "Any other indications that Americans are being prevented from returning home in some way, shape, or form, would serve as disincentives to support that may be absolutely vital to the international response to this growing crisis," Phelan said.
Craig Spencer, a doctor who developed Ebola after volunteering in Guinea in 2014 and who was attacked online by Trump, said in an interview four years later that it was already difficult to find nurses and doctors who could take the time to volunteer. The possibility of not returning home would mean fewer people would be able to help, the epidemic would continue, and the risks to everyone would increase with a less-controlled outbreak: "a pure disaster," Spencer said.
When asked if this policy would deter volunteers, Pillai pointed to existing organizations in the Democratic Republic of the Congo and Uganda that "have been integral in providing healthcare support" already.
When passengers on the hantavirus-stricken cruise ship were flown back to the US, officials first ruled out the idea of mandating quarantine. But now, they are requiring certain passengers to remain in the Nebraska biocontainment facility until the end of the month, even though some passengers have attempted to leave and quarantine at home.
"The decision was made across the leadership in the US government to have the passengers stay in Nebraska until 31 May, which marks the 21st day of their monitoring period," David Fitter, the CDC's hantavirus lead, told journalists on Tuesday. "We're constantly regarding the situation and evaluating where things are."
The decision reportedly came from Jay Bhattacharya, who is performing some of the duties of CDC director until the nominee is confirmed by the Senate. Angela Perryman, a 47-year-old woman who had conversations with a passenger who later died from the Andes virus, told the New York Times that she had tested negative and had no symptoms, and would like to quarantine in an Airbnb in south Florida. Another passenger, a 30-year-old man, said he would like to quarantine in New York state.
Bhattacharya rose to prominence by pushing back against public health measures, which he loosely terms "lockdowns," in the Covid pandemic. In 2023, he criticized the US Air Force Academy for quarantining cadets; two students later killed themselves. Bhattacharya highlighted the "harms of social isolation" and said the situation was "tragic."
"Any public health measure that is imposed has to be based on reasonable scientific evidence or principles, and has to be proportionate and necessary to achieve the public health outcome," Phelan said.
The guiding concept in global health law is implementing "the least restrictive measure necessary to achieve the public health outcome," she added. If a measure is more restrictive than necessary, then it is infringing on personal rights.
Most people want to follow quarantine directions, but they may be more comfortable in their own home, where the long quarantine time may be more bearable. In public health, "the preference is to use voluntary home quarantine as the least restrictive option available," Phelan said.
In the case of passengers testing negative with no symptoms and a safe way to return home, "I could see a reasonable judge making that conclusion," she said.
There is a previous case for comparison, dating back to the Ebola outbreak of 2014. When Kaci Hickox, a nurse who treated patients in West Africa, returned to the United States, the CDC did not require her to quarantine in a facility. But Chris Christie, the then-governor of New Jersey, attempted to mandate quarantine, a move that eventually the courts rejected.
