Air Travel and Disease

February 4, 2020

AS THE HEADLINES have it, we’re half a step from the end of civilization. Global Health Emergency! Deadly Virus! Lockdown! Here in Boston, the mayor urges residents to “stay calm.” At the airlines, crews were refusing to staff China-bound flights until carriers pulled the plug entirely. United, American and Delta all have suspended China flying until the spring at the soonest. Several European, Asian and African airlines have done the same. On a Sri Lankan Airlines flight dispatched to Wuhan (pictured above), the crew wore full hazmat suits. Aboard a U.S. domestic flight last weekend, a flight attendant wore a mask. “I’m probably overreacting,” she explained. “But I don’t want to die.”

And so on.

All of this over a virus that gives you the proverbial “flu-like symptoms” and then, for the vast majority of its victims, moves on. Sure a small number have died, most of them elderly or compromised by other illness. That’s the case with many viruses that, for most people, result in no permanent harm. Imagine for a moment the panic we’d be seeing if this were a truly dangerous pandemic capable of killing millions — something unknown and untreatable.

Consider: in the United States this winter 180,000 people have been hospitalized for influenza. Close to 10,000 have died, including 68 children. Globally, between three and five million people are expected to contract the flu, killing up to 650,000 of them. That’s the flu. Normal old seasonal influenza. We’ve been dealing with it for months now. Where were the crews refusing to fly, the canceled flights, the isolating of entire cities and the crowds stampeding for paper masks? Unless I’m missing something in the logic, our yearly grapple with the flu should have brought air travel to a grinding halt.

The coronavirus outbreak brings with it certain unknowns: transmission methods and patterns, and so on. I get that. Still, the mass hysteria and overreaction we’re seeing is more worrying as the illness itself. The mortality rates for coronavirus are believed to be lower than they are for influenza, while the World Health Organization has stated that the travel restrictions and quarantines are unnecessary and could only make the problem worse. “W.H.O. advises against the application of any restrictions of international traffic,” says the agency’s latest statement. “Based on the information currently available.” But as these things go, sober reasoning gets buried in the noise. I’d like to type something trite like, Has society gone mad? But maybe that isn’t so trite, because it has gone mad. It went mad a long time ago; this is just the newest symptom.

Am I being irresponsible? Too cavalier? I can, at least, sympathize with the mechanics of this story. The potential is very real and very frightening. What we’re watching unfold in real time is the template of a perhaps inevitable catastrophe. Call it a dress rehearsal.

And the airplane, bless it, is in many ways the focal point. If you’re an aerophile like me, you take a certain perverted pride in that. Such an important thing, this airplane. If you’re a normal person, you probably find it terrifying. As you should. Air travel is, if nothing else, an exquisitely efficient vector for the spread of pathogens. Not because planes themselves are incubators of disease, but because of how quickly they move vast numbers of people around the globe.

Once after arriving in the United States on a flight from Africa, I noticed a lone mosquito in the cockpit. How easy it would be, I thought, for that tiny stowaway to escape into the terminal and bite somebody. Imagine an unsuspecting airport worker or passenger who has never before left the country, and suddenly he’s in the throes of some exotic tropical sickness. Actually, it’s been happening for years. Cases of “airport malaria” have been documented in Europe, resulting in several deaths after faulty or delayed diagnosis. It’s just a matter of time before this happens in America, if it hasn’t already.

In 2014, at the height of the Ebola crisis, I became ill on a plane returning from Ghana. It was mostly a gastric thing, but with a high fever as well. (To this day I’m unsure what the culprit was, but it’s not by accident that in all my trips to that country since, I’ve never gone back to Epo’s, a popular chicken and noodle place in the Osu neighborhood.) I wasn’t especially worried, and wanted nothing more than to grab my commuter flight home. But the Port Authority paramedics who met the plane had other ideas. Ghana was free of Ebola, but to them, “Ghana” sounded a lot like “Guinea,” where indeed the disease was raging. That’s literally all it took. Thus I found myself ordered into an ambulance and left alone for two hours in the parking garage at Jamaica Hospital, while the staff figured out what to do with me. Then another hour in a quarantine chamber while a nurse, costumed for Chernobyl or a voyage to Neptune, yelled at me from across the room.

“Look,” I said. “I don’t have Ebola. But whatever I do have, it’s getting worse the longer you leave me sitting here!”

Where I’m going with that I’m not sure. I suppose my point is twofold. First, to emphasize the dangers of hysteria. I was basically hospitalized against my will because the country I was coming from happened to begin with the letter “G.” But also, yes, to illustrate just how ruthlessly jetliners can, potentially, push contagions from one corner of the globe to the other.

To this point we’ve been lucky. The dangers from coronavirus or salmonella chicken are minimal. But who knows what maladies the future holds, in a world moving full-speed toward environmental cataclysm. We will see this again, and next time it could be worse.

Author’s photo.

Meanwhile, as we ride this out, if you’re nervous about getting on a plane, remember that the likelihood of catching something is no greater than it would be in any crowded space: a movie theater, a restaurant, a subway platform. While you can’t entirely rule out the possibility, unless you’re sitting very close to an infected person, chances are low. And when people do become ill from flying, it’s usually from something they touch, not from something they breathe. Lavatory door handles, armrests and tray tables are the dirtiest parts of an airplane cabin. The air is much cleaner than people think. A portion of the air is recycled, it’s true, but all of it is filtered and there’s a total change-over every several minutes.


For an update on which airlines have suspended or curtailed service to China, SEE THIS LIST.


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10 Responses to “Air Travel and Disease”
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  1. Sarah McGuire says:

    Hi Patrick, I really appreciate your blog and it has helped me to (partly) get over my fear of flying, at least enough to resume flying.

    So I’m all about a rational response to threats and I appreciate a logical approach.

    No, COVID-19 isn’t the zombie flu or anything. But it is a new illness that overwhelms medical systems by using up available resources (beds, equipment, people) and by infecting medical workers. Moreover, there is an unknown but apparently high rate of “severe” illness with COVID-19. I’m talking about people needing ventilators and other intensive care, not someone feeling lousy at home for a week. Without advanced care, most of those people would die. And any possible long-term effects are a complete unknown.

    This has some predictable effects. Break your arm? have chest pain? need chemo? good luck and get in line, and also you are at high risk of getting infected in a hospital. Does your country not have enough ventilators/beds/doctors? that is very bad, because now there are none for you.

    So no, we shouldn’t panic or freak out. And heavens no, we should not engage in conspiracy theorizing or racial profiling or any other stupidity. But it is actually a serious threat to world health, and we should all be preparing at every level, just the way we should all pay attention to preparing for other realistic potential threats like earthquake, hurricane, or tornado.

  2. Andy says:

    Another physician endorsement here. We’re obviously seeing a lot of people freak out about this but I then I see a good percentage of them refuse to get a flu shot. I’m also an FAA AME and one of the things that I learned when I do my aerospace CME is actually how little viruses spread within an airplane. I had some ill conceived notion that someone in the front of the plane could spread the virus to someone in the back row as the circulation went from front to back (it does). This is a resource I share with some of my patients who travel…

  3. Ted says:

    Great read as usual. One nitpick on your flu stats: “Globally, between three and five million people are expected to contract the flu, killing up to 650,000 of them.” I think these number come from the WHO, if so the 3-5 million are cases of “severe illness”. Presumably the total number of people who _contract_ seasonal flu is much higher going by the < 1% mortality rate that I've seen cited.

  4. Noor says:

    Excellent read ! I’m a physician and I endorse your well reasoned argument about the mass hysteria about pandemics which in my view is actually augmented by the information asymmetry between what experts know about this epidemic and the knowledge that trickles down to public coupled with the unregulated social media. I do , however, wonder if airlines can take some extra precautionary measure to prevent its spread in the planes like using disposable trays, disinfecting sprays on lavatory door knobs and providing hand sanitizers to the travellers? As novel Corona Virus has a long incubation period of 14 days and a person remains contagious during this period, airlines collectively need to come up with unique, innovative but less intrusive prevention measures.

  5. Lily Wong says:

    As of now >20,600 have been infected and >400 have died—that is, if the figures from China are real. Considering how China arrested the 8 doctors who first exposed the virus, China has been covering this up for a long time. Videos leaked from Wuhan show that a lot of people have died and they were not included in the statistics. Yes panic is no use. But one should be well aware of other political factors in play. And WHO is no longer a reliable source of information as it is corrupted by China—look at all those African airlines that have suspended flights to China. No one is flying except Ethiopia, where the WHO comes from. The virus is deadly, highly contagious, and since Jan 16, the number of infected has gone up by 500 times. It is not fair to say people panic—panic is the first line of defence, so that people can take precautions. And as of now, Hong Kong’s border is still open to China. Everyday 15,000 people are still arriving from mainland China, and many of them are transiting all over the world via Hong Kong. And do not expect them to be honest about their travel history. In this way the virus is spreading around the world via Hong Kong. The world should be on high alert.

  6. Bob Palmer says:

    My back of the envelope calculation says the current corona virus has a kill rate of about 2%. And maybe much lower because infected individuals are probably undercounted while deaths are probably not. So, what’s 2%? No big deal?

    Then I thought about it this way: I live on the edge of a small city of 4,000 out here on the prairie. If we lost 2% of our citizens that would be eighty people. And I would probably know many of them. And yeah that is a big deal. I pray for all those who are affected by this disease.

  7. Bruce says:


    The reason Australian evacuees were treated like this was, of course, that they were almost all ethnically Chinese.

    If an outbreak like the coronavirus had happened somewhere that loads of white Australian twentysomethings hang out, like LA or New York or London or Berlin, none of this would have happened. For one thing, I’m not even sure that there would be an evacuation, as our media wouldn’t be calling it “The Chinese Disease”. For another, if there were an evacuation, the government would be promising to Bring Our Aussie Kids Home, and would do it immediately.

    Almost every aspect of international media and government response to the coronavirus has smacked of racism. Quite apart from the morality, I don’t think this approach is helping to save lives.

  8. Bruce says:

    ***”Ghana was free of Ebola, but to them, “Ghana” sounded a lot like “Guinea,””***

    I think there’s an elephant in the room that we’re missing here, both with ebola and the coronavirus.

    Ghana doesn’t just sound like Guinea. Ghana, like Guinea (and indeed the DRC, where Ebola was at its worst) is full of African people.

    The coronavirus might not be as dangerous as flu, but it comes from Hubei, which is a place full of Chinese people. And SARS, another coronavirus, also came from China, which is full of Chinese people.

    I don’t know whether you’ve followed Australian reactions to the coronavirus – why would you? – but it’s been an absolute car crash, while also being quite symbolic of global reactions. Australians in Wuhan were told they’d be evacuated. But the Australian government forgot to negotiate with the Chinese government to arrange this. The evacuation was not back to a quarantine centre in their home country proper (as it was for British and Japanese evacuees, for example), but to a former immigration detention camp on Christmas Island, 2000km from the Australian coast and 2,600km from the nearest decent hospital. They were told they’d be charged A$1000 for the flight to Christmas Island (this was rescinded after an outcry), and there was no indication as to how they would leave the island after their quarantine.


  9. Eric says:

    Part of me wishes that China would come out of the 15th century with respect to the “exotic” items they carry in their markets. As long as their culture finds it acceptable to eat dogs and other animals that are the source of these outbreaks, they should be prepared to be shunned and isolated on the global stage as a result.

    Perhaps part of their culture needs a reformation towards basic standards of hygiene with respect to what items are acceptable to have in a food market, and how they are prepared…essentially, they need to join civilized international society on some levels.

    It’s one thing to cling to cultural touchstones, but not at the expense of incubating and spreading disease to the rest of the world.

  10. Dror Maor says:

    I’m asking seriously.
    If the entire city of Wuhan (home to 11 million people) is quarantined, doesn’t that indicate that we’re NOT taking this too far?
    Great article as always, thanks.