By Asaf Bitton, MD, MPH
I know there is some confusion about what to do next in the midst of this unprecedented time of a pandemic, school closures, and widespread social disruption. As a primary care physician and public health leader, I have been asked by a lot of people for my opinion, and I will provide it below based on the best information available to me today. These are my personal views, and my take on the necessary steps ahead.
What I can clearly say is that what we do, or don’t do, over the next week will have a massive impact on the local and perhaps national trajectory of coronavirus. We are only about 11 days behind Italy and generally on track to repeat what is unfortunately happening there and throughout much of the rest of Europe very soon.
At this point, containment through contact tracing and increased testing is only part of the necessary strategy. We must move to pandemic mitigation through widespread, uncomfortable, and comprehensive social distancing. That means not only shutting down schools, work (as much as possible), group gatherings, and public events, but also making daily choices to stay away from each other as much as possible to Flatten The Curve below.
Our health system will not be able to cope with the projected numbers of people who will need acute care should we not muster the fortitude and will to socially distance each other starting now. On a regular day, we have about 45,000 staffed ICU beds nationally, which can be ramped up in a crisis to about 95,000. Even moderate projections suggest that if current infectious trends hold, our capacity (locally and nationally) may be overwhelmed as early as mid-late April. Thus, the only set of strategies that can get us off this concerning trajectory are those that enable us to work together as a community to maintain public health by staying apart.
The wisdom, and necessity, of this more aggressive, early, and extreme form of social distancing can be found here. I would urge you to take a minute to walk through the interactive graphs — they will drive home the point about what we need to do now to avoid a worse crisis later. Historical lessons and experiences of countries worldwide have shown us that taking these actions early can have a dramatic impact on the magnitude of the outbreak. So what does this enhanced form of social distancing mean on a daily basis, when schools are cancelled?
Here are some steps you can start taking now to keep your family safe and do your part to avoid a worsening crisis:
1. We need to push our local, state, and national leaders to close ALL schools and public spaces and cancel all events and public gatherings now.
A local, town by town response won’t have the adequate needed effect. We need a statewide, nationwide approach in these trying times. Contact your representative and your governor to urge them to enact statewide closures. As of today, six states have already done so. Your state should be one of them. Also urge leaders to increase funds for emergency preparedness and make widening coronavirus testing capacity an immediate and top priority. We also need legislators to enact better paid sick leave and unemployment benefits to help nudge people to make the right call to stay at home right now.
2. No kid playdates, parties, sleepovers, or families/friends visiting each other’s houses and apartments.
This sounds extreme because it is. We are trying to create distance between family units and between individuals. It may be particularly uncomfortable for families with small children, kids with differential abilities or challenges, and for kids who simply love to play with their friends. But even if you choose only one friend to have over, you are creating new links and possibilities for the type of transmission that all of our school/work/public event closures are trying to prevent. The symptoms of coronavirus take four to five days to manifest themselves. Someone who comes over looking well can transmit the virus. Sharing food is particularly risky — I definitely do not recommend that people do so outside of their family.
We have already taken extreme social measures to address this serious disease — let’s not actively co-opt our efforts by having high levels of social interaction at people’s houses instead of at schools or workplaces. Again — the wisdom of early and aggressive social distancing is that it can flatten the curve above, give our health system a chance to not be overwhelmed, and eventually may reduce the length and need for longer periods of extreme social distancing later (see what has transpired in Italy and Wuhan). We need to all do our part during these times, even if it means some discomfort for a while.
3. Take care of yourself and your family, but maintain social distance.
Exercise, take walks/runs outside, and stay connected through phone, video, and other social media. But when you go outside, do your best to maintain at least six feet between you and non-family members. If you have kids, try not to use public facilities like playground structures, as coronavirus can live on plastic and metal for up to nine days, and these structures aren’t getting regularly cleaned.
Going outside will be important during these strange times, and the weather is improving. Go outside every day if you are able, but stay physically away from people outside your family or roommates. If you have kids, try playing a family soccer game instead of having your kids play with other kids, since sports often mean direct physical contact with others. And though we may wish to visit elders in our community in person, I would not visit nursing homes or other areas where large numbers of the elderly reside, as they are at highest risk for complications and mortality from coronavirus.
Social distancing can take a toll (after all, most of us are social creatures). The CDC offers tips and resources to reduce this burden, and other resources offer strategies to cope with the added stress during this time.
We need to find alternate ways to reduce social isolation within our communities through virtual means instead of in-person visits.
4. Reduce the frequency of going to stores, restaurants, and coffee shops for the time being.
Of course trips to the grocery store will be necessary, but try to limit them and go at times when they are less busy. Consider asking grocery stores to queue people at the door in order to limit the number of people inside a store at any one time. Remember to wash your hands thoroughly before and after your trip. And leave the medical masks and gloves for the medical professionals — we need them to care for those who are sick. Maintain distance from others while shopping — and remember that hoarding supplies negatively impacts others so buy what you need and leave some for everyone else. Take-out meals and food are riskier than making food at home given the links between the people who prepare food, transport the food, and you. It is hard to know how much that risk is, but it is certainly higher than making it at home. But you can and should continue to support your local small businesses (especially restaurants and other retailers) during this difficult time by buying gift certificates online that you can use later.
5. If you are sick, isolate yourself, stay home, and contact a medical professional.
If you are sick, you should try to isolate yourself from the rest of your family within your residence as best as you can. If you have questions about whether you qualify or should get a coronavirus test, you can call your primary care team and/or consider calling the Massachusetts Department of Public Health at 617.983.6800 (or your state’s department of health if you are outside of Massachusetts). Don’t just walk into an ambulatory clinic — call first so that they can give you the best advice — which might be to go to a drive-through testing center or a virtual visit on video or phone. Of course, if it is an emergency call 911.
I realize there is a lot built into these suggestions, and that they represent a real burden for many individuals, families, businesses, and communities. Social distancing is hard and may negatively impact many people, especially those who face vulnerabilities in our society. I recognize that there is structural and social inequity built in and around social distancing recommendations. We can and must take steps to bolster our community response to people who face food insecurity, domestic violence, and housing challenges, along with the many other social disadvantages.
I also realize that not everyone can do everything. But we have to try our absolute best as a community, starting today. Enhancing social distancing, even by one day, can make a large difference.
We have a preemptive opportunity to save lives through the actions we take right now that we will not have in a few weeks. It is a public health imperative. It is also our responsibility as a community to act while we still have a choice and while our actions can have the greatest impact.
We cannot wait.
Asaf Bitton, MD, MPH, is the executive director of Ariadne Labs in Boston, MA.