Policy-relevant lessons emerge from analysis of Ebola outbreak

York U’s Steven J. Hoffman analyses the 2014-2016 Ebola outbreak. His findings could inform future evidence-based policy and decision-making.

Population and public health look at the health status and outcomes of large groups of people, while epidemiology considers the evolution of disease. All three are concerned with evidence-informed policy, best practices and prevention, which Canada has traditionally championed. It was under this lens, as well as a sharp legal eye, that York Professor Steven J. Hoffman and law student Ali Tejpar examined Canada’s response to the 2014-2016 West African Ebola outbreak.

“International and domestic law must be an important instrument for achieving and protecting public health.”
̶   Professor Paul McDonald, Dean, Faculty of Health

Hoffman wears many hats. He is the Scientific Director of the Canadian Institutes of Health Research’s Institute of Population and Public Health (now based at York) and is cross-appointed between York’s School of Health Policy and Management and Osgoode Hall Law School. With one foot in law and another in population health, there’s no better scholar to analyze Canada’s response to the Ebola crisis.

Steven Hoffman

Steven J. Hoffman

Hoffman’s findings, published in the peer-reviewed Canadian Yearbook of International Law (2017), found there was room for improvement. “Canada’s visa restrictions targeting Ebola-affected countries were not in line with the legally binding International Health Regulations (IHR) that the World Health Organization (WHO) was enforcing,” Hoffman explains. “Historic global health champions like Canada must demonstrate their leadership in evidence-informed policy.”

“Steven’s work is an example of how public policies need to be mindful of both domestic and international law. Failure to do so may mean that legal channels are used to repeal or actively shape policy that impacts public health,” says Professor Paul McDonald, Dean, Faculty of Health. “The essential point is that international and domestic law must be an important instrument for achieving and protecting public health.”

Ebola virus one of most challenging outbreaks

Named after the Ebola River in the Republic of Congo, the Ebola virus disease (EVD) is a life-threatening illness that carries with it a fatality rate of around 50 per cent, according to WHO. Though initially transmitted from animals, such as gorillas or fruit bats, to humans, the disease now travels from human to human via direct contact through broken skin or mucus membranes.

The Ebola virus

The Ebola virus

Primary symptoms include fever fatigue, headache, sore throat and muscle pain. The next phase is comprised of vomiting, diarrhea, rash, symptoms of impaired kidney and liver function, and in some cases, both internal and external bleeding, such as oozing from the gums, according to WHO.

Makoua, Congo, 2013: A sign warns visitors that the area is Ebola infected.

Makoua, Congo, 2013: A sign warns visitors that the area is Ebola infected

The first outbreaks occurred in the mid-1970s in Central African villages near tropical rainforests. The 2014–2016 outbreak in West Africa was different because it involved major urban areas as well as rural ones. WHO described this outbreak as one of the most challenging threats to global health that it had ever encountered.

By the end of the outbreak (late March 2016), over 28,000 people had been diagnosed and over 11,000 had died. The severity of this outbreak caused widespread fear and panic.

WHO calls for IHR compliance; Canada imposes travel bans

On August 8, 2014, WHO Director-General Margaret Chan declared the Ebola outbreak a “public health emergency of international concern” and mandated that WHO members adhere to their obligations under the IHR, which are a legally binding and evidence-based set of rules governing how countries prevent and respond to the international spread of disease. The IHR makes it clear that countries must prevent and control the disease’s international spread while avoiding unnecessary interference with international traffic and trade.

WHO Headquarters in Geneva, Switzerland

WHO Headquarters in Geneva, Switzerland

The Canadian government responded, but opted to sidestep the IHR. It chose a different path compared to other high-income countries by implementing restrictive travel measures. Citing section 87(3) of the Immigration and Refugee Protection Act, the government instructed Citizenship and Immigration Canada (now Immigration, Refugees and Citizenship Canada) to stop processing temporary and permanent residence visa applications from foreign nationals who had been in Ebola-affected areas in the past 90 days before their application date. These visa restrictions prevented non-Canadians who had been in Ebola-affected states from entering, transiting, visiting or living in Canada within three months of their travels.

Canada’s decision goes against consensus, evidence

Canada’s cancellation and restriction of travelers’ visa applications from Ebola-affected states breached the IHR and hindered global health efforts, Hoffman concludes. “Canada’s response went against public health authorities’ consensus views, the best available scientific evidence on disease transmission, and the WHO’s recommendations,” Hoffman explains.

He argues that the evidence points to the most appropriate response to the crisis. “The best available scientific evidence manifestly demonstrates that the harms of travel restrictions outweigh their benefits,” says Hoffman.

Most significantly, according to Hoffman, the Canadian government’s response undermines the country’s historic role as an advocate and guardian of scientifically based, evidence-informed policy.

The WHO’s Director of Global Capacities, Alert and Response, Dr. Isabelle Nuttall, told Maclean’s magazine (November 8, 2014) that Canada’s response violated the spirit of the IHR. “We will continue to state loudly that WHO is against that [Canada’s response], that it shouldn’t happen,” Nuttall stated.

“Historic global health champions like Canada must demonstrate their leadership in evidence-informed policy.”
̶   Steven J. Hoffman

Larger issues come to fore when anticipating next epidemic

Canada’s response to the Ebola crisis is only half of the story. Two much larger issues came to the fore, according to Hoffman: (1) The IHR’s legal and moral authority seemed to be ineffective in this crisis. (2) IHR compliance, and WHO’s authority to enforce the IHR, was called into question.

“The troubling reality that approximately 70 per cent of WHO states parties have not developed core public health capacities to monitor and prevent diseases — as legally required by the IHR — demands urgent action to coordinate and finance the necessary health infrastructure to prevent future outbreaks,” Hoffman explains.

Looking to the future, he presses for Canada to once again demonstrate its historic leadership in evidence-informed policy, and restore its position as global health champion.

The article, “Canada’s Violation of International Law during the 2014–16 Ebola Outbreak,” was published in Canadian Yearbook of International Law (2017). To learn more about Hoffman, visit his faculty page. Also see the media release.

By Megan Mueller, manager, research communications, Office of the Vice-President Research & Innovation, York University, muellerm@yorku.ca