key: cord-0791477-1x287ina authors: Hartsock, Jane A.; Head, Katharine J.; Kasting, Monica L.; Sturm, Lynne; Zimet, Gregory title: Public Perceptions of the Ethical Permissibility of Strict Travel Restrictions to Mitigate Transmission of SARS-CoV-2 date: 2022-03-01 journal: Transp Res Interdiscip Perspect DOI: 10.1016/j.trip.2022.100577 sha: 78b4ac01c014a5dd1761906360dce671491a0482 doc_id: 791477 cord_uid: 1x287ina Although there has been extensive exploration of public opinion surrounding many non-pharmaceutical interventions (NPIs) aimed at mitigating transmission of SARS-CoV-2 (e.g. mask-wearing and social distancing), there has been less discussion of the public’s perception of the ethical appropriateness other NPIs. This paper presents the results of a survey of U.S. adults’ opinions of the ethical permissibility of both state-to-state and international travel restrictions to mitigate transmission of SARS-CoV-2. Our research revealed overall high agreement with the ethical permissibility of both state-to-state and international travel restrictions, though we saw significant difference across political party affiliation and conservative/liberal ideologies. Other factors associated with agreement with state-to-state travel restrictions included increasing education, increasing income, and both high and low commitment altruism. When considering international travel restrictions, income, education, and low commitment altruism were associated with increased agreement with the ethical permissibility of international travel restrictions. Ethical analysis and implications are explored. Introduction: In December of 2019, the World Health Organization (WHO) was advised of the hospitalization of a patient with an unexplained pneumonia in the city of Wuhan, China (Andersen, et al., 2020; WHO, 2021) . The virus was subsequently identified as SARS-CoV-2 and first appeared in the United States approximately a month later, on January 20, 2020 (IHME, 2021). By March of 2020, the virus was confirmed in more than 110 countries worldwide (Andersen, et al., 2020) . As governments grappled with how to effectively mitigate transmission of this novel coronavirus, one early measure that was taken included limiting travel by people both within and between countries affected by the virus. The United States issued its first global air travel restriction on February 2, 2020 (AJMC, 2021; Chinazzi, et al. 2020 ) and later expanded restrictions to include a complete ban on entry to the United States by non-Americans traveling from 26 European countries (AJMC, 2021) . Whether related to these travel restrictions, various "stay-at-home" orders, or as a result of voluntary reductions in movement (Abouk and Heydari, 2021; Jacobson and Jacobson, 2021) , travel specifically in the United States declined sharply during this same time period. Notably, TSA records indicate air travel dropped from 2,151,626 travelers on March 31, 2019, to 136,023 travelers on March 31, 2020 (TSA, n.d.) . This is consistent with research demonstrating substantial reduction in mobility (Wellenius, et al., 2021) and use of "shared modes" of travel (e.g. public transportation, ride hailing, carshare) during the early months of the pandemic (Ozbilen, et al. 2021 ). The relationship between disease spread and mobility is significant and complex. Rafiq, et al, provide an excellent summary of the existing literature concerning the relationship between mobility and spread of infectious diseases, including SARS-CoV-2. For example, as early as the 14 th century during the bubonic plague pandemic, it was understood that limiting the movement of people would limit the spread of the disease. Similarly, during the first surge of the COVID-19 pandemic, mobility was the best predictor of daily cases (Rafiq, et al., 2022) . Additionally, there is a significant "bi-directional relationship" between mobility and spread of infectious disease, meaning "mobility can affect the spread and the spread can also influence the mobility in reverse" (Rafiq, et al., 2022) . This bi-directional relationship is illustrated in modeling that suggests increased vaccination may facilitate transmission as vaccination is positively correlated with human mobility (Guo, et al., 2021) . January 2020 and April 2021 demonstrated, among other important findings, that even at the county level, human mobility had a positive effect on the COVID-19 infection rate (Rafiq, et al., 2022) . Additionally, orders restricting mobility resulted in lower mobility indicating that regardless of public outcry, these orders do affect people's patterns of movement (Rafiq, et al., 2022 in an attempt to limit the spread of this contagious virus (IHME, 2021). These restrictions have, in some instances, hampered the movement of essential medical personnel and supplies necessary to adequately respond to the pandemic (Devi, 2020) . They further have impaired the ability to provide technical support for things like contact tracing to countries in the developing world and to utilize passenger aircraft to deliver cargo carrying PPE and ventilators (Devi, 2020) . While public opinion and compliance surrounding the two most common NPIs (i.e. mask-wearing and social distancing) have been well studied during the COVID-19 pandemic (Allcott, et al., 2020; Kahane, 2021; Kasting, et al. 2020; Wong, et al., 2020) , there has been limited analysis of what might be considered more restrictive interventions: those implicating one's freedom of movement. In the United States, the federal restrictions on travel affected primarily international air traffic while state restrictions relative to travel have been inconsistent with fewer than half of states having any restriction whatsoever placed on individuals engaged in state-to-state travel (National Academy for State Health Policy, 2021). Of those that did, most were limited to quarantine requirements for out-of-state travelers, meaning those entering the state. This paper examines the public's perception of the ethical appropriateness of these arguably more intrusive government measures, specifically, (1) state and federal officials prohibiting residents from traveling to other states; and (2) federal officials prohibiting Americans from traveling to other countries. Detailed methodology has been previously published elsewhere Kasting, et al. 2020; Sturm, et al., 2021 Participants were asked a modified version of a previously validated 18-item altruism scale (Rushton, et al. 1981) . This original scale consisted of 18 questions assessing frequency of engagement in various altruistic activities (e.g. helping a stranger push their car out of the snow or mud) on a Likert-type scale from 1=never to 5=very often. The scale was modified to 17items to reflect more modern altruistic activities. We conducted a principal components exploratory factor analysis, which extracted two factors. We labeled the first factor, which consisted of six items (Cronbach's α=0.85), high commitment altruism (i.e., behaviors that require a relatively high level of personal involvement; e.g., "I have, before being asked, volunteered to look after a neighbor's pets or children without being paid for it"). We labeled the second factor, which consisted of four items (Cronbach's α=0.81), low commitment altruism (i.e., behaviors that require a relatively low level of personal involvement; e.g., "I have given money to charity"). We calculated a mean score for each of the altruism subscales. Relevant beliefs included COVID-related worry, perceived severity, and perceived community threat. Worry and perceived severity were assessed with a three-term scale modified from the literature and posed only to those participants who had not had COVID. Worry was assessed with a three-item scale modified from the literature (Fan, et al., 2018; Liau, et al., 1998) . Items assessed participants' worry related to getting COVID-19 on a 5-point Likert scale from 1=strongly disagree to 5=strongly agree. The three items (Cronbach's α=0.82) were summed and averaged into a single scale with higher numbers indicating higher COVID-19-related worry. Perceived severity was measured using a modified four-item scale (Cahyanto, et al., 2016) . Items assessed participants' perceptions of the severity of COVID-19 disease (e.g. "I am afraid that I may die if I contract COVID-19") on a scale of 1 (strongly disagree) to 5 (strongly agree) so that higher scores indicate higher perceived severity. The four items (Cronbach's α=0.71) were summed and averaged to derive a single perceived severity score. Perceived community threat was assessed with a single item, "Do you think COVID-19 infection is a major problem in your community?" with a binary yes/no response option. We assessed both political ideology and political party affiliation. Political ideology was assessed with a single question, "In general, how would you describe your political views?" with participants being classified as liberal, moderate, or conservative. They were then asked, "How would you describe your political party affiliation?" with response options including Democratic, Republican, Independent, Other, and prefer not to answer. First, we described the sample using n(%) or means and standard deviations. We further described the sample by indicating the percentages (for continuous variables) or point-biserial correlations (for dichotomous variables) for each variable's association with each primary outcome. We then conducted binary logistic regression analyses separately for each variable with agreement with both state-to-state and international travel restrictions. Variables that were significant in bivariate analyses at p<0.01 (this conservative cutoff was selected because of our large sample size) were included in subsequent two-step hierarchical logistic regression analysis. Specifically, demographic variables were entered in step 1, and attitudes/beliefs were entered in step 2. Statistical analyses were conducted using SPSS statistical software (SPSS Inc., version 25, Armonk, NY, 2017). A total of 16,706 invitations were sent out for the survey, 4,042 people opened the survey, 351 indicated they did not wish to participate, and 42 indicated they were younger than 18 years. A total of 3,586 completed the survey and 3,499 answered both questions regarding travel restrictions and were included in the statistical analyses comparing the groups. In considering the relationship between political party affiliation and decreased support for state-to-state travel restrictions, one explanation for this may be tied to attitudes towards individual liberties, states' rights, and suspicion of "big government" which tend to track party These findings may also be understood in the light of implementation of actual international travel restrictions during this pandemic, specifically restricting travel to and from China. Some media outlets characterized these measures as xenophobic and part of the same racially motivated behavior that gave rise to use of pejorative phrases like "The China Virus" and "The Wuhan Flu" (Campbell, 2020; Ollstein, 2020; Penny, 2020) . As participants were not invited to explain why they opposed or supported one view over another, further research which queries individuals' reasoning for their responses may assist particularly in better understanding discordant attitudes towards state-to-state and international travel restrictions in the face of a public health crisis. In addition to these unanticipated findings, we also noted that in Step 2 of our regression, high commitment altruism switched from predicting agreement with state-to-state restrictions to predicting views that such restrictions were not ethically permissible. Thus, when various health behaviors such as individual worry about contracting or becoming severely ill from COVID were factored in, high commitment altruism correlated with decreased rather than increased agreement with the restrictions. It is unclear what led to this phenomenon, which implicates more targeted research to identify the source of this result. However, one possible explanation may be that in the presence of negative views about one's individual risk of harm from COVID, a concern for others (as is inherent in altruistic behaviors) translates to an agreement that it is ethically permissible to "escape" the risk, thus a decreased agreement with restrictions on that ability to escape. Step 2 of our regression, perceived severity of COVID (i.e. concern that one may die if they contract COVID) switched from predicting agreement with international travel restrictions to predicting decreased agreement perhaps for similar reasons. As a final matter, one's receptiveness to mitigation measures undertaken by federal and state governments, broadly, must be understood in the light of significant levels of distrust of public health organizations. Research by the Robert Wood Johnson Foundation and the Harvard School of Public Health found that although positive ratings of the medical system increased between 2009 and 2020 (from 36% to 51%, respectively), the public's perception of the public health system declined during that same period of time (from 43% to 34%, respectively) (Robert Wood Johnson Foundation, 2021). Importantly, less than half of Americans surveyed above indicated "a great deal of trust" in: their local health department (44%); their state health department (41%); the Surgeon General (40%); the NIH (37%); and the Department of Health and Human Services (33%). This lack of trust tracks party lines, as well. Significantly fewer Republicans than Democrats indicated a "great deal of trust" in key public health organizations, and this was consistent across every level of government as compared to Democrats: local health department (38% v. 53%), state health department (22% v. 59%), and Department of Health and Human Services (22% v. 43%) (Robert Wood Johnson Foundation, 2021). Our study did not analyze these variables or measure trust within the context of support for travel bans; though future research examining the relationship between political affiliation, trust, and views of individual public health entities could be fruitful. Despite the unusual results in Step 2 of our regression, the overall, broad agreement with travel restrictions gives rise to important considerations regarding the potential consequences of instituting such restrictions, particular international travel restrictions. As has been previously articulated in the literature, the spread of infectious diseases is strongly determined by the travel patterns of individuals between regions (Camitz and Liljeros, 2006) . This is a reflection of "outbreak dynamics" as a combination of both "the local epidemiology of the disease and the global mobility of diseased individuals" (Linka, et al., 2020) . This has been illustrated with the global spread of SARS-CoV-2 in which regional and international travel has contributed to the pandemic (Petersen, et al., 2020) suggesting that restriction of mobility may be a "highly effective measure to manage the outbreak dynamics" (Linka, et al., 2020) . Research specifically as to the SARS-CoV-2 pandemic has demonstrated clear benefit from travel restrictions. For example, modeling done by Chinazzi, et al, of the initial February 2020 international travel bans demonstrated a "77% reduction in cases imported from mainland China to other countries." Despite the association between international travel and spread of infectious diseases, as noted above the WHO and others have warned that "travel bans" "are usually not effective in preventing the importation of cases, but have a significant economic and social impact" (Petersen, et al., 2020) . Still, others have noted that restrictions on international travel merely delay the spread of infectious diseases, and that the effect is short-lived unless combined with measures aimed at reducing transmissibility such as detection and isolation of infected individuals along with the use of NPIs in the population (Chinazzi, et al., 2020; Huizer, et al., 2015) . This is particularly true when considering air travel for which research demonstrates relative ineffectiveness of measures such as exit and entry screening, quarantine, or travel restrictions (Huizer, et al., 2015; Swaan, et al., 2014) . Accordingly, the concerns of WHO pertaining to the negative economic impact of travel restrictionsa phenomenon that disproportionately impacts poor and developing nations -should be understood in the light of a merely temporary and limited benefit of delayed spread. Ultimately, this places our study in the ironic position of indicating generally high support for a significant restriction on freedom of movement, in the face of research suggesting that less burdensome efforts (e.g. mask-wearing) are likely to have a much more significant impact on mitigating transmission (Huizer, et al., 2015; IHME 2021) . This dissonance may be somewhat contextualized by the time period of data collection (May 2020) when anxiety about the virus was high and the full-scale politicization of NPIs had not yet completely unfolded. Mask-wearing in particular has become a partisan activity which implicates in-group behavior. Interestingly, research has shown that receptivity to mask-wearing corresponds with shared political information rather than perceptions of risk (Howard, 2021) or effectiveness (Kasting, 2021) . Travel has not entered the political discussion to this same degree or in quite so explicit terms. Moreover, mask-wearing has become, at least in part, an outward expression of political party affiliation, making it to some extent analogous to wearing a team hat or campaign t-shirt. Travel, whether domestic or international, does not implicate personal expression in this same way. Additionally, travel restrictions and mask-wearing, while both NPIs, are not otherwise similar: a travel restriction may have limited impact on an individual affecting perhaps only one or two planned trips, while mask-wearing is a repeated behavior one must enact daily. Future research may clarify the different levels of support and agreement for various NPIs during this pandemic. Our study does have some limitations. At the time data were collected (May 2020), there was no vaccine available and it was unknown whether and when one would become widely accessible. Thus, the evaluation of the ethical permissibility of travel restrictions is necessarily from the vantage point of limited pharmaceutical interventions. Additionally, while the study includes a large aggregate number of individuals, it is not a representative U.S. sample. Because of this, we were unable to extrapolate our findings to regional or state-specific views and, therefore, have not attempted to do so in this paper. Moreover, these data are self-reported and are therefore subject to recall and social desirability biases. However, given the anonymous nature of the survey, we believe the social desirability bias is minimized. Further, because there was no opportunity for participants to expound on their impressions of these restrictions as ethically appropriate, it is difficult to deduce the source of the unexpected difference in demographics between state and federal travel restrictions. Finally, while participants in our study indicated a general impression of travel restrictions as ethically permissible, this may not translate to a general willingness by Americans to acquiesce to such restrictions. The public's understanding of mask-wearing as effective in contrast to its practice of actually wearing masks (Kasting, et al, 2021) is an example of the dissonance between what the public know, believe, and understand, and what behavior they are willing to exhibit. As the United States continues to grapple with the SARS-CoV-2 pandemic, and on the dissonance between an understanding of what is the right thing to do and a willingness to perform that behavior, particularly in the context of a public health crisis where one's behavior has implications for both oneself and others, has significant implications for researchers in philosophy, ethics, and psychology. Given the warnings of experts that global pandemics are likely not to be "once in a century" occurrences going forward (Tollefson, 2020) , it is imperative to understand the way the public approaches the various restrictions governments are likely to institute to curb transmission of infectious diseases. 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