This piece presents a high-level summary of the international travel restrictions implemented during the initial outbreak of SARS-COV-2 in Wuhan, China.
Travel restrictions and border controls can prevent pathogens travelling long distances and entering new populations, making them powerful tools in the initial fight against contagious outbreaks. If we can learn how to use them effectively, we can protect whole populations at once, thereby greatly reducing the threat posed to humanity by pandemic-potential viruses.
January 2020 was a busy month for the Irish media. Between the impeachment of the 45th President of the United States of America (I dare not say his name) and the UK's final departure from the European Union, there were few column inches left for any other global news - least of all 'one of those things' that only ever happens 'over there'. As a result, the early stages of the COVID-19 outbreak received little attention in Ireland, and a key pandemic data set went largely unnoticed.
This piece intends to address that gap, and to further our understanding of the role border control policies can play as public health tools in the immediate response to a contagious outbreak.
In an era of mass migrations and low-cost flights, the world is more connected than ever before. Air travel was a key driver in the spread of the SARS-COV-2, just as it was for SARS-COV-1. We know that air travel has the potential to trigger future epidemics and to spread them to every corner of the world, so it is essential that we learn to manage risk along this vector. The sooner that work starts, the better.
NB: The border policies referenced in this piece were sourced from worldaware.com (now a part of crisis24.garda.com). I have not confirmed every entry in their dataset, but I have found no errors to date and am happy to publish these results on my personal blog. However, a single source may contain errors – of both omission and commission – so the data would need a more thorough review before being used as part of any official research or analysis.
1st – 21st of January: Initial Responses
Taiwan, Singapore, & Vietnam
On the 1st of January 2020, the WHO announced that a pathogen of unknown origin was circulating in Hubei province, China.
Most western governments took little notice of the announcement - they were more concerned with Brexit and the fallout from the US presidential election - but the Taiwanese were alert to the danger. They began screening passengers arriving on flights from Wuhan on the same day, with officials from Taiwan’s CDC performing on-flight inspections before passengers disembarked. Two days later, Singapore announced that it too would screen passengers, performing temperature checks on all those arriving from Wuhan into Changi Airport. Two days after that, Vietnam announced health checks at gates along its 500km border with China.
We knew very little about the virus at the time. We had no idea how long it had been circulating or how fair it had spread. We couldn’t say anything about its transmissibility, its virulence, or which cohorts of our population were most vulnerable. What we did know was that it was contagious, likely deadly, and that we had neither vaccine nor cure for it.
That (somewhat paradoxically) was exactly the information we needed to justify taking action. With a pandemic-potential virus on the loose, and set against a backdrop of much uncertainty, these Asian nations fell back to a natural, human instinct – protection. They did not wait for international consensus, nor seek approval from a higher authority. They acted quickly, independently, and with the health and safety of their people foremost in mind.
India, the USA, and North Korea
India and the USA were next to act. They introduced airport screening measures for passengers from China on the 14th and 17th of January, respectively.
Some commentators might have interpreted those actions through a political lens, given the tensions that exist between these global powers – India and the USA being allies in the new Cold War with China. However, that narrative would not have lasted long, as on the 21st of January, North Korea – dependent on China for its very existence – cancelled all flights to and from its sponsor with immediate effect.
Instead of asking why India and the USA acted next, perhaps we should ask why every other nation did not. Why did it take two full weeks before any of them to recognised the risk at their borders? Weren’t they aware of the immediate responses from China’s neighbours? Didn’t they know about China’s history with these kinds of viruses?
Perhaps the WHO will have to shoulder some of the blame.
The information flow out of China had been sketchy through the first few weeks of January, with the WHO’s upbeat messaging consistently confounded by the reality on the ground. But the WHO’s overly optimistic communication seemed to have assured the world that urgent action was not needed. Certainly, there was none forthcoming.
Or perhaps the world wasn’t paying attention to the WHO at all. India implemented its measures the day after the first overseas case was confirmed, in Thailand. The USA acted the day after the virus was confirmed in Japan. North Korea closed its border the day after the first case was discovered in South Korea. It seemed that these nations were paying more attention to the path of the virus than the WHO’s announcements.
If so, that was all about to change.
22nd – 24th of January: Human-to-Human Transmission
On the 23rd of January 2020, the WHO made an announcement which, in hindsight, might prove to be one of the most consequential of the last 20 years – or indeed the next 20 – though they probably didn’t know it at the time.
Despite the WHO’s breathless praise for China’s containment efforts, the virus had continued to move faster and further than anyone had expected. Cases had now been confirmed in Thailand, Japan, South Korea, the USA, Taiwan, Vietnam and Singapore, and it was all but inevitable that more would be identified, but no one knew where or how many.
Recognising the danger, the WHO convened the IHR Emergency Committee for the 22nd and 23rd of January. As the meeting was brought to a close, the Director General of the WHO, Dr. Tedros Ghebreyesus, confirmed what many by that stage had suspected – this novel Chinese virus could be transmitted from human to human.
The significance of that announcement cannot be overstated.
Up to that point, the WHO had been hoping that the virus would only transmit from animals to humans. In that case, the only humans at risk would have been those who had come into contact with one of the infected animals in the Huanan Seafood Market - a tiny percentage of Wuhan's population. The outbreak would have remained a regional problem within Hubei province, and the news cycle would have moved back to Brexit. and Trump.
But the pace of the virus’ spread outside of China had created serious doubts about that narrative. As the number and geographical spread of the international cases grew, it became increasingly difficult for the WHO to maintain the position that so many people who had been to one food market in Wuhan, had also coincidentally booked international flights for the following weeks.
Of course, they hadn’t. The reality was that the virus had been spreading silently among the people of Wuhan since at least the 31st of December (and most likely for quite a few weeks before then), and many of those people had since flown from China to seed new infections abroad, but, how many? When had they left? And where were they now?
We had no answers to those questions; we could barely even guess.
The WHO Warns The World
Perhaps the WHO had been slow to admit it to themselves because they knew what it implied, but once human-to-human transmission was confirmed, everything changed. The situation was now orders of magnitude more dangerous that the world had hitherto been led to believe, and the WHO was compelled to update its advice.
In its daily situation report, the WHO recognised that this new coronavirus had the potential to seed a pandemic. Accordingly, it changed its global risk assessment from ‘Moderate’ to ‘High’, sending a message to every nation in the world – whether they had close ties to China or not – that they needed to take immediate precautions.
We were now dealing with a deadly pathogen which could jump from one side of the world to the other and seed new clusters of transmission in new territories in less than 48 hours (it had already done so). More cases would surely follow, and any nation receiving direct flights from Wuhan was squarely in the line of fire. That group of nations included Australia, Japan, South Korea, Singapore, Taiwan, Thailand, France, Italy and the UK, underlining the speed at which the virus could transmit to distant populations.
Thankfully, that risk appeared to be well-understood.
I wondered earlier whether the world was paying any attention to the WHO in the first weeks of January. Well, now I had my answer.
Australia, Japan, Vietnam, Singapore and South Korea all implemented policies on the WHO’s announcement. The USA, Mexico and Canada did too. Scores of nations across South East Asia, the Middle East and Africa followed suit. I won’t list them all but Indonesia, Philippines, Malaysia, Thailand, Saudi Arabia, the UAE, Kuwait, Bahrain, Egypt, Tunisia, Nigeria, Ghana, Kenya, Uganda, and South Africa were among them. The world was listening.
The situation was so serious that the Chinese even implemented border controls on themselves! Hong Kong stopped all high-speed rail connections with the mainland, while the CCP blocked all travel in and out of Wuhan (road, rail and air), later following up with more travel restrictions on cities throughout Hubei province.
25th of January – 2nd of February: A PHEIC
By the end of January, most countries in Asia, Africa, and the Middle East were screening passengers arriving from the Chinese mainland. Some countries had even blocked travel entirely but, despite all of this activity, the virus continued to find its way into new territories. It had been identified in every province of China, and isolated cases had now been confirmed in Australia, the Philippines, the UAE, the USA, German, France, Spain and the UK, among many others.
To make matters worse, we now had evidence that the virus was seeding clusters of community transmission outside of China. Thailand, South Korea and Singapore – three of the earliest nations to be infected – now had domestic outbreaks of their own to manage, in addition to stopping the virus at their borders. It was a clear warning to the world of what might happen if the nations did not move quickly and decisively enough to stamp it out.
The warnings kept coming.
On the 30th of January, the IHR Emergency Committee met again and this time it declared the outbreak to be a ‘Public Health Emergency of International Concern’ (‘PHEIC’). The declaration of a PHEIC is reserved for the most serious of global health threats and this was only the 6th time that it had been made in its 15 years of existence. The message was clear: this is an emergency, and it is an emergency for everyone.
The Starting Gun
When the historians look back on this crisis, they will see that the declaration of the PHEIC was, in effect, the official starting gun for the world’s pandemic response. You might have been able to convince yourself that the threat wasn’t serious, or that it wouldn’t make its way to your neck of the woods, but the PHEIC had put an end to those delusions. If you weren’t putting protections in place now, you were already behind, and this was your final warning. There could be no excuses from here on in.
Up to this point, the WHO had reacted slowly to the outbreak and its communications had been poor, and both of these errors cost the world lives. The WHO should be held accountable for that, but it should also be recognised that be declaring the PHEIC, it had eventually given the world the warning it needed to hear. Now it was the responsibility of the world’s governments to ensure that things didn’t get worse. The next big announcement would be the declaration of a pandemic – an outcome which we still had time to avoid.
Thankfully, the nations heeded the WHO’s warning. They realised that airport screening wasn’t getting the job done and that stronger measures would be needed.
Israel and the USA cancelled all flights from China, and they received widespread disapproval from the global media. Italy, the Maldives, and Papua New Guinea implemented identical policies, but their actions barely received any attention at all.
Kazakhstan and Russia closed their borders with China to land crossings. Hong Kong added mandatory hotel quarantine to all travellers from the mainland. Australia and New Zealand – who both receive direct flights from China – coordinated a travel ban on all foreign nationals with recent travel history on mainland China, just as their cousins in the Pacific Islands had done the week before.
Sri Lanka cancelled visas issued to Chinese tourists. Taiwan did the same, and then repatriated some Chinese tour groups which had recently arrived. Singapore banned all travellers with recent travel history in Wuhan, whether they were Chinese or not. Mongolia banned everyone!
The nations were clearly understood the significance of the threat, and they were willing to take the necessary steps to protect the health of their people. Clearest of all, the nations had decided that the best course of action was to keep the virus as far away from their populations as possible. Border controls couldn’t guarantee that the virus wouldn’t get in, but they were the best way to minimise its path into the country.
It didn’t matter which side of the geopolitical divide you were on either. Russia, Pakistan, Turkey, North Korea… all are allies of China and all implemented some form of entry ban on Chinese citizens around this time. African nations which are dependent on China for trade and investment did too, and none of that should surprise us. This wasn’t about politics; it was all about survival.
3rd – 8th of February: An Astonishing Volte Face
The existing research on border controls was sparse. The WHO had issued a report on non-pharmaceutical interventions in 2019 however its main conclusion was that there simply wasn't enough evidence to come to firm conclusions about their effectiveness (see images below).
IMAGE 1: The WHO on Screening
IMAGE 2: The WHO on Internal Travel Restrictions
IMAGE 3: The WHO on Border Controls
Border controls also tend to be politically contentious, and the WHO will always try to avoid any topic or argument which risks irking its paymasters. Naturally, the WHO had withheld its opinion on the matter.
“For the moment” Tedros told the IHR Emergency Committee on the 23rd of January, 2020, “the WHO does not recommend any broader restrictions on travel or trade”. The WHO added that if nations did want to impose border controls, they should inform the WHO first, as per the International Health Regulations (2005).
And yet, something about the flurry of border controls in late January must have disturbed the WHO. At the declaration of the PHEIC, on the 30th of January 2020, Dr. Tedros listed 7 recommendations to prevent the spread of the virus. There was a marked shift in Dr. Tedros' tone, and his new priority was clear:
“First, there is no reason for measures that unnecessarily interfere with international travel and trade. WHO doesn’t recommend limiting trade and movement.”
Less than a week later, he added extra force to his exhortations:
“we reiterate our call to all countries not to impose restrictions inconsistent with the International Health Regulations. Such restrictions can have the effect of increasing fear and stigma, with little public health benefit.”
It was an astonishing volte face.
Up to this point, the WHO had stayed out of the debate on travel restrictions as they had little research on which to base any recommendations. But now, it seemed that Dr. Tedros had taken it upon himself to actively discourage any and all border controls.
His sudden shift wasn’t just out of line with the WHO’s official position at the time, it was also out of line with the historical record.
International travel restrictions had been a key public health policy during the SARS outbreak in 2003. The WHO – then under the leadership of Dr. Gro Bruntland – had quickly realised that if a virus could remain hidden for a few days or more, it could be on the other side of the world in days, and without anyone knowing. The international air network therefore represented a key source of risk, so the WHO developed international travel policies to address those dangers, and this innovation was recognised as having contributed positively to the world’s successful response to that outbreak.
The COVID-19 virus was more contagious than the SARS virus, and the world was even more connected than it had been 20 years before. Surely the case for border controls was even stronger this time around? Surely this was an opportunity for the WHO to build on its previous work, and to further our understanding of border controls as modern public health policy tool?
Out of the blue, the WHO had switched from neutral on border controls to negative, and without any additional data or research to justify the move. One day they told us that “For the moment, the WHO does not any broader restrictions on travel”, implying that there was a potential role for border controls – but not at this time. A week later, they were 'reiterating their call' NOT to impose restrictions, and without any explanation for the change of policy.
It was a bizarre shift, especially given the timing.
The Logic of Border Controls
Minimising the presence of a deadly, contagious pathogen in the population is always the best possible outcome for the public health. This is especially true in the early days of a contagious outbreak, when the viral load is smallest and we have the possibility of suppressing the outbreak, then eradicating it entirely.
Furthermore, by minimising the viral load coming into your own country, you also minimise the amount that gets out, which means border controls help to protect your neighbours too. If everyone is blocking the virus from getting in, then how can it get out? A co-ordinated travel restriction therefore has the potential to stop an outbreak in its tracks.
Last but not least, what other options did we have?
Testing capacity was meagre in early February, so we had no way of finding the virus in the population. Domestic contact tracing functions were under-developed and poorly resourced. There were no medicines or therapeutics to deal with infections when they occurred, while any vaccine would have been many months away. So apart from travel restrictions and other border controls, what other options did we have? How else was the world going to protect itself from the virus?
And wasn’t Dr. Tedros aware that China was imposing travel restrictions on itself? How could travel restrictions be any more effective within China’s expansive borders, than they would be across them? If so, why not question China's use of internal controls? And if this really was such a dangerous virus, why weren’t we doing everything in our power to stop it travelling across borders and into new populations?
So many questions. Something about this just didn't make sense.
WHO? What?? Why??!
The WHO was consistently behind the curve throughout January 2020. It had downplayed the risk of the virus and had overstated the strength of China’s response. It had been slow to recognise H2H transmission and then slow to declare the PHEIC. But at least with that declaration, it seemed as though the WHO had finally caught up with the seriousness of the outbreak, and that it was working to make up lost time.
But Dr. Tedros’ exhortations on China’s behalf had sent us back to square one – trying to work out what exactly was going on. How could we reconcile the WHO’s inconsistent communications with the catastrophic images we were seeing in the news media? How could we square it all with the common sense in our heads?
All we know is that the WHO had no opinion on border controls, then Dr. Tedros visited Xi Jinping in China on the 28th and 29th of January, and when he returned on the 30th of January, Tedros was pleading for the world not to put any travel restrictions on China. As to whether Dr. Tedros' visit to China had any effect on his thinking or on WHO policy, well, your guess is as good as mine.
Over the next few weeks, the number of new border restrictions slowed significantly, and most of the new restrictions applied to travellers from South Korea and Iran, reflecting both the world’s continued trust in the WHO and the outbreak’s shifting centre of gravity.
How It Played Out Over February And March
Since the virus’ arrival 5 weeks before, the world had watched as the story went from a suspicious outbreak, to the identification of a novel coronavirus, to the confirmation of human-to-human transmission, and finally, to the declaration of a PHEIC.
In that time, the information flow had been patchy, but the virus’ progress had been consistent, and concerning. The outbreak had continued to grow in China (where it was now out of control) and new cases had been confirmed in 20+ countries across Asia, Europe, the Middle East and North America. Community transmission had begun to develop in some of those locations, with more reports surely to follow.
Given the unreliable information flow and the lack of pharmaceuticals with which to combat the disease, many nations had taken the sensible approach of trying to block the virus getting into their populations. Some relied on weaker measures like health and temperature screening at airports, others had closed their borders entirely, but all were pursuing the same goal: to keep the virus out.
The only major regions which hadn’t tried to stop the virus getting into their populations were South America and Europe. South America receives no direct flights from China, so border controls weren’t an option there. Europe, on the other hand, receives millions of Chinese visitors every month, with planeloads arriving directly from Wuhan into Rome, Paris, and London.
This risk should have been a major concern for Brussels. It should have prompted a swift and decisive response, but it wasn’t until the 17th of March – a week after the pandemic had been declared and more than 6 weeks after the declaration of the PHEIC – that the EU to finally took steps to protect its Member States from this deadly pathogen.
The bureaucrats couldn’t countenance national border closures (of course), but they decided that the ‘EU border’ was definitely a real thing, and that it should be protected as one (even though it had already been breached). Accordingly, they announced a total travel ban on all travellers entering the bloc from non-EU territories. It was far too little, far far too late but it achieved the EU's goal of being seen to be doing something.
The agreement would have been unanimous, but one Member State refused to close any part of its border for any reason.
March 2020 came and went, and Ireland remained the only country in the EU – and probably one of the few in the world – not to make any attempt to stop the COVID entering its population. Every other EU nation implemented at least one policy intended to stem the flow of the virus into their populations and to reduce the risk to the nation's public health – whether it was airport screening, flight bans or border closures – but not the Irish.
Excuses were made at the time, and they will be made again, but the truth of the matter is that the Irish authorities did not lift a finger at this key juncture to protect Ireland’s people from an invisible, but deadly threat. That looks to be a huge mistake. To put this in context, even Boris Johnson and Alexander Lukashenko did more to protect their people during this crisis than Fine Gael or NPHET.
With all of that in mind, I think we can make a set of statements about border controls which should elicit no controversy:
A large number of nations – and a significant majority by population – used border controls as public health policy tools during the initial SARS-COV-2 outbreak.
The pattern of implementation had little to do with politics, xenophobia, or racism, and almost everything to do with national leaders’ desire to protect their people from a deadly, contagious pathogen.
Travel restrictions were official WHO policy during the SARS outbreak, and were recognised as an essential component of the world’s successful response to that outbreak.
The WHO stated in 2019 that it did not have enough high-quality research to come to any firm, scientific conclusions about the effectiveness, or not, of border controls.
On the discovery of a novel and highly-contagious coronavirus in January 2020, and with no extra data and having done no further research, the WHO decided to contradict its own research, and advised the world against the use of border controls.
The world's leaders were listening to the WHO. Had the WHO advocated strongly for border controls, the world would have followed its advice.
The COVID crisis presented an opportunity for the WHO to develop this new and potentially powerful public health tool. Given how connected the world has become over the last 30 years – and how connected it is likely to remain for the foreseeable future – it stands to reason that some experimentation would have stood to the world in the decades to come.
Regrettably, the WHO missed the opportunity.
To make matters worse, the border controls which were implemented appeared to be working!
The nations which performed the best during the first wave (eg Taiwan, Singapore, Vietnam, New Zealand, Australia) were also among the first to screen flights from China. They were among the first to block them too. Moreover, the nations which were slowest to implement border controls were also among the worst performers over that time eg Ireland, the UK, the ‘core’ EU nations.
There are many other variables which confound the analysis, however I think it is telling that the most competent nations also made the most effort to keep the virus out of their populations. I also think it is worth further investigation.
The main weakness of this approach was that the border policies were implemented independently, and with no coherence or common goal. The co-ordination of international public health policies is usually one of the WHO’s key roles but, on this occasion, the WHO had chosen to abandon that responsibility. With no official advice in place, it should be no surprise that we ended up with a patchwork of dis-jointed efforts which eventually fell apart - a fair summary of the whole pandemic, don’t you think?