November 7, 2014
Tom Frieden, MD, MPH
Centers for Disease Control and Prevention
1600 Clifton Road
Atlanta, GA 30329-4027
Dear Director Frieden:
We write as professionals, activists, and public health researchers who have worked to combat AIDS and other infectious diseases in the United States and around the world for over three decades. We have not forgotten how HIV/AIDS was at first largely ignored while it appeared to affect only marginalized communities, or the stigma generated as fear of the virus took hold in the larger population. We have watched with growing concern as Ebola virus disease (EVD) was ignored far too long while it spread in some of the poorest countries in the world, and how initial apathy has now led to hysteria here in the U.S., based on only a handful of cases.
We applaud the leadership provided by the Centers for Disease Control and Prevention’s Interim U.S. Guidance for Monitoring and Movement of Persons with Potential Ebola Virus Exposure, released October 27 and since updated, including the recommendation for direct active monitoring of asymptomatic individuals in the “high-risk” (e.g., direct contact with Ebola-infected bodily fluids without correctly wearing appropriate personal protective equipment, or PPE) and “some-risk” (e.g., direct contact with Ebola-infected bodily fluids while correctly wearing PPE) exposure categories. This is an evidence-based strategy to ensure that individuals who do become infected are quickly entered into care and to break chains of transmission.
We are, however, concerned about the CDC allowance for public movement and assemblage restrictions for completely asymptomatic individuals in the “some-risk” exposure category. For this population, particularly those in compliance with direct active monitoring recommendations, such restrictions are de facto quarantines. There is no evidence to suggest that these restrictions provide any additional public health benefit.
Unnecessary public health practices for completely asymptomatic “some-risk” individuals entering or returning to the U.S. may have consequences that are the antithesis of effective public health policy. Implementation of these public movement or assemblage restrictions, especially if overzealous or discriminatory, could lead U.S.-bound individuals who have had direct contact with EVD patients to deny this to health authorities at airports, or to schedule alternate travel itineraries that circumvent entry reporting and airport screening requirements. This would undermine the most important evidence-based components of any effective strategy to break EVD transmission chains: prompt diagnosis, isolation of those with bona fide symptoms, and clear guidance for those with possible EVD exposure.
We also fear that the uncertainty caused by patchwork and ever-shifting guidelines, along with the fear of ambiguous and/or draconian U.S. entry requirements, will greatly hinder efforts to recruit the skilled and experienced personnel needed to confront the epidemic in West Africa. Groups such as Médecins Sans Frontières, Partners in Health, and the United Nations have stressed the desperate need for more qualified health care providers in Guinea, Liberia, and Sierra Leone to save the lives of those infected, prevent the ongoing spread of the disease in those countries, and to stem the risk of outbreaks elsewhere.
EVD responders must know what will be required of them when they return home so they can plan accordingly. Though CDC lists factors for state or local health authorities to consider in determining if public movement and assemblage restrictions should be mandated for asymptomatic individuals in the “some-risk” exposure category, including failure to comply with direct active monitoring requirements, we are concerned that many of these factors are exceptionally vague and therefore be interpreted subjectively and implemented in a discriminatory fashion.
Unnecessary practices by local health authorities will also promote the stigma and discrimination already being directed toward people of West African origin or descent and health care personnel here in the U.S., regardless of their exposure to EVD.
We will continue to advocate against unnecessary, harmful, and inconsistent quarantine policies, and want to urge state and local officials to instead follow national, evidence-based protocols established by the CDC. However, the fact that the Interim U.S. Guidance provides broad and subjective allowances for local health officials to require public movement or assemblage restrictions for “some-risk” asymptomatic individuals undermines our call for alignment with national public health leadership and permits potentially stigmatizing and discriminatory state or local practices.
We urge you to withdraw federal support for these restrictions, noting the absence of any evidence that they are necessary or effective for individuals engaged in direct active monitoring, and recognize the significant risk such restrictions pose to controlling further spread of EVD.
We urge you to apply the lessons of sound policy in the U.S. and stand with us in solidarity against the hysteria, ignorance, and political opportunism that pose a risk to public health and our ability to respond effectively to EVD in West Africa. We stand in solidarity with the people of West Africa and elsewhere who are struggling with too few resources combating an emerging epidemic that can be stopped with courageous and evidence-based leadership.
Marce Abare, MD, Montefiore Medical Center
Jeton Ademaj, ACT UP New York
Doug Allen, Columnist, Aspen Daily News
Diane Anderson-Minshall, Editor in chief, HIV Plus Magazine
Heather Arculeo, Co-Chair PWN, Peer Navigator Christie’s Place
Jennifer Avril, Member, ACT UP and ACT UP Women’s Caucus
Madeleine Ballard, Last Mile Health
Karen Bateman, AIDS Activist, the SERO Project
Rosheen Birdie, Student, UC Berkeley
Reginald Brown, HIV/Hep-C Screener Unity Fellowship Church
Nina Bruer, Harm Reduction Spec.
Guillermo Chacón, President, Latino Commission on AIDS
Gabi Clayton, Co-Founder, Families United Against Hate
Robert Cohen, Physician
Steven Cordova, Hospital Worker
Darrel Cummings, Chief of Staff, Los Angeles LGBT Center
Margaret Cunningham, RN, MPH
Anne-christine D’Adesky, Journalist, Author of Moving Mountains: The Race to Treat Global AIDS
Julie Davids, AIDS Activist
Paul Davis, Director of Global Campaigns, Health GAP
Erin Drinkwater, Executive Director, Brooklyn Community Pride Center
Debra Elliff, LPN
Kenyon Farrow, US & Global Health Policy Director, Treatment Action Group (TAG)
Judith Feinberg, Professor of Medicine/Infectious Diseases, University of Cincinnati
Anna Forbes, Independent Consultant
Ken Fornataro, The Kabocha Factory
Gerald Friedland, Professor of Medicine and Epidemiology and Public Health, Yale School of Medicine
Eric Friedman, O’Neill Institute for National and Global Health Law, Georgetown University Law Center
Joel Gallant, Associate Medical Director of Specialty Services, Southwest CARE Center
Honora Gibbons, ACT UP/ MOVING EQUIPMENT
Global Network of People Living with HIV, North America
Gregg Gonsalves, Global Health Justice Partnership, Yale Law School and Yale School of Public Health
Peter Gordon, MD, Columbia University
Janet Hall, Peer Coach
Mark Harrington, Executive Director, Treatment Action Group (TAG)
Andy Harris, MD
David Hoos, MD, MPH, Public Health Consultant, New York, NY
Tim Horn, HIV Project Director, Treatment Action Group (TAG)
Brittni Howard, NAU M.A. Applied Anthropology Candidate
Olga Irwin, PWN-USA, Ohio Regional Co-Chair & Outreach Coordinator
Charles King, President/Chief Executive Officer, Housing Works, Inc.
Janet Kitchen, President, Positively U
Gil Kudrin, Director of Development, Nightsweats & T-cells, Co.
Gerald G. Lakatos, MSW
Jay Laudato, Executive Director, Callen-Lorde Community Health Center
Joseph Lim, Ph.D. Candidate, MIT
Kelsey Louie, CEO, GMHC
Amanda Lugg, Director of Advocacy, African Services Committee
Suraj Madoori, Manager, HIV Prevention Justice Alliance and AIDS Foundation of Chicago
Marcelo Maia, AIDS Activist
Fernando Mariscal, Program Director, Community Access, Inc.
Liesl Messerschmidt, Director, Health and Development Consulting International
Marya Meyer, Citizen
Carol Murphy, COO/CNO, HELP/PSI
Shagarrian Newcomb, AIDS Activist, American Medical Student Association
Mark Niedzolkowski, Director of Operations, PWA Health Group
Corann Okorodudu, Professor of Psychology & Africana Studies, Rowan University
Vincent Pelletier, CEO, AIDS / Coalition PLUS France
David Phillips, HIV & Global Health Activist
Laura Pinsky, Columbia University
Ben Plumley, CEO, Pangaea
Lee Raines, Activist
Asghar Rastegar, Professor of Medicine, Yale School of Medicine
Mike Rose, Medical Student and Partners in Health Community Coordinator
Luis Scaccabarrozzi, Director of Health Policy & Advocacy, Latino Commission on AIDS
Stephanie Schroeder, Independent Activist
Rev. Michael Schuenemeyer, Executive, United Church of Christ Health and Wholeness Advocacy
J. Walton Senterfitt, Epidemiologist and Ethicist
Jon Shaffer, Senior Strategist for Grassroots Organizing, Partners In Health
Zara Shah, Partners in Health Community Coordinator for Binghamton, NY
Virginia Shubert, JD, Shubert Botein Policy Associates
Sue Simon, Public Health Advocate
Laura Skrip, Yale School of Public Health
Kimberleigh Smith, VP, Policy & Advocacy, Harlem United
Christa Sprinkle, Board Secretary, Portland Area Global AIDS Coalition (PAGAC)
Peter Staley, AIDS Activist
Sean Strub, POZ Founder
Melanie Thompson, Principal Investigator, AIDS Research Consortium of Atlanta
Michael Tikili, National Organizer, Health Global Access Project
US PLHIV Caucus
Wim, Vandevelde, Chair, TB CAB
Andrew Velez, ACT UP New York
Terri Wilder, AIDS Activist
Michelle Wilson, HIV/AIDS Advocate
Doug Wirth, President/Chief Executive Officer, Amida Care, Inc.
Steffie Woolhandler, MD, MPH
Dale Wrigley, Director of Engagement & Advocacy, Saint Louis Effort for AIDS (SLEFA)
Brian, Zabcik, ACT UP/New York
cc: Ron Klain
Ebola Response Coordinator
Executive Office of the President
Secretary of Health and Human Services
Department of Health and Human Services