In response to the rising Covid-19 death toll and case counts in the U.S., calls for a national lockdown have been escalating. In an open letter to America’s decision-makers, more than 150 medical professionals urge them to “shut it down now, and start over.” In the letter, they argue that people should “stay home, going out only to get food and medicine or to exercise and get fresh air.”
I empathize with the urgency in their plea for people to stay home. I felt helpless watching patient after patient die from Covid-19 while working in a New York hospital in April. In the Northern California Covid-19 clinic I work in, I continue to see patients infected with and harmed by the virus. I, too, am desperate for this pandemic to end.
But I believe that telling people to stay home and avoid all nonessential social interactions is the wrong way forward. We should instead focus on educating people and helping them socialize safely. Lessons from sex education indicate that this will be a more effective approach.
A national lockdown is politically impossible today given widespread unemployment and the deepening recession, not to mention the federal government’s failure to coordinate a national response and the extreme politicization of the pandemic.
Telling people to stay home will worsen the mental health epidemic brought on by Covid-19. Michelle Obama recently admitted that “there have been periods throughout this quarantine, where I just have felt too low.” She is not alone. Since the pandemic started, loneliness has increased by 20% to 30%, and emotional distress has more than tripled. This is not surprising: Numerous studies have demonstrated deleterious effects of social isolation on physical and mental health.
Without widespread understanding of how to socialize safely, the cooped-up need for social connection will lead to surges of long-awaited get-togethers and new infections when lockdowns end. We have already seen this phenomenon in Florida and Arizona. It is happening across Europe. In the urgent care clinic where I work, I have seen an increasing number of people who developed Covid-19 symptoms after attending an indoor get-together following months of judicious social distancing.
If telling people to stay home isn’t the answer, then how do we slow this pandemic? By helping them socialize safely.
Several months into the pandemic, we know more about SARS-CoV-2, the virus that causes Covid-19, how it spreads, and how to reduce its transmission from person to person. We know that infection via surfaces is uncommon, and that outdoor transmission is even rarer. We know that face coverings and physical distancing significantly reduce the virus’s spread. At a hair salon in Missouri, for example, two stylists with Covid-19 interacted with more than 100 clients and infected none of them, thanks to the salon’s policy of having stylists and clients wear face coverings.
Instead of insisting that people stay home and indefinitely postpone seeing their loved ones and friends, we should be helping people socialize in ways that minimize the risk of spreading Covid-19.
At an individual level, socializing safely means taking into consideration various factors that determine the risk of coming in contact with SARS-CoV-2: wearing a face covering; frequently washing your hands; being aware of how close you are to others, and for how long; the number of nonhousehold contacts you are with; and ventilation.
Putting that into practice looks like this: Hang out outdoors with a few people instead of indoors with many. Wear a face covering when physical distancing is not possible. Stay home at the smallest hint of fever, fatigue, or cough. Don’t share food or drinks. Limit your social circle and consider creating a “Covid-19 bubble” with one or two close households. These relatively simple steps can help us meaningfully connect with one another without significantly increasing the risk of developing Covid-19.
At a community level, people should be educated about the Covid-19 risks associated with various social activities. Going to the grocery store or playing a noncontact sport like tennis are low-risk activities, while going to a bar or attending a crowded indoor religious service are high-risk activities. Such information, though available, is far from being commonplace knowledge.
It is also essential to enable safe socialization by both making it easy and enforcing it. Closing off streets to cars and painting reminders for physical distancing in public parks and stores are a start, but we can do more. Just as lifeguards at a beach or pool monitor swimmers and discourage them from behaving unsafely, public officials should be deployed in crowded places to remind people to socialize safely and make face coverings freely available to those who need them.
And until the pandemic is under control, the highest-risk activities, such as indoor dining or large concerts, should be discouraged, if not banned.
Some may argue that this “socialize safely” message will backfire and lead to more risky social interactions. There are a few reasons that likely won’t be the case.
One comes from another field of public health: sexual health. Proponents of “abstinence only” education worry that comprehensive sexual education, which covers sexually transmitted diseases, condom use, and safe sexual practices — along with abstinence — leads to increased sexual activity among teens. Yet studies have repeatedly shown that the safe-sex curriculum actually reduces rates of unprotected sex, sexually transmitted diseases, and unwanted pregnancies.
In the context of this pandemic, the “safe socialization” approach has proven successful in other countries. In Japan, people are asked to avoid the 3 C’s — closed spaces, crowded places, and close contact. Instead of self-isolating at home, Canadians are encouraged to exclusively hang out with another household in a “double bubble.”
Telling people to stay home backfired early in the pandemic, resulting in protests, premature reopenings, risky social activities, and the worst Covid-19 pandemic in the world. We can avoid making the same mistake if we choose to accept our social and political realities, heed the latest scientific evidence, and help people socialize safely.
Jason Bae is an internal medicine physician in northern California and medical director of Prealize Health, a company that uses machine learning to power proactive health care.
need situation specific advice
1. in home distancing for household with vulnerable/aged adult and child at school
2. home schooling support for children diagnosed by track and trace – home for 2 weeks and losing time
3. arrangements for vulnerable teachers in school. e.g. no clss contact, more marking? setting up support for quarnateed children
haven’t seen any for gov.uk!
Never goping to work well in America. Too many disbelievers (It is just the flu, it is a hoax, etc..) and too many who do not want their “rights” infringed upon. It may woprk in some select communities, but overall this is an idealistic approach that ignore simple human nature. As an example…In our own community this summer we have had impromptu street parties for that collected 200-400 people at a time, and they were not there for social distancing.
Cultural and racial issues also come into play, as sad as that may be.
Liked your article & points made. We certainly need guidance since covid-19 is not going to go away anytime soon. We cannot afford to stay home just because. Pediatrician from epicenter Miami. Thanks.
Jason, thanks for this. This is a really intelligent posting: thoughtful, constructive, and it even implies a plan that might be testable. I hope something comes of your analysis. I am old, and retired, and not terribly optimistic. But then I read an article like yours, and think, “Well, maybe… just maybe…something good comes of this.” Anyway, congratulations.
Thank you for your kind words, Dr. Block.
What about winter months? It’s too cold too meet up outside here December through February, and into March.
So like the Swedes did – successfully we now know?
It is not likely that a safe, effective vaccine that will be taken up by many will be available any time soon. Meanwhile, we will have to learn to live with this virus. Most serious illnesses and deaths occurred among the already sick such as those in nursing homes. The vast majority of cases are mild and don’t require hospitalization. We do need to stop with scare talk.
To be clear, I don’t think Swede’s approach was necessarily the right approach, and the lockdowns in March in the U.S. was the right move. The mistake we made was that it was not followed by people socializing safely.
It is true that this virus disproportionately affects those who are elderly and with chronic medical conditions, however, it doesn’t make their premature death from this virus any less tragic. I have also cared for many relatively healthy patients in their 40’s and 50’s, some of them unfortunately have died.
I believe another lockdown at this point is just not possible politically. But, we can teach people to socialize safely AND also educate them about the potential devastating and long-lasting health effects of the virus.
For clarification, “I believe the lockdowns in March in the U.S. was the right move.” The sentence structure in the original reply was confusing.
I was glad to see a view that recognizes the potential for change through consistent, persistent educational messages and actions targeted to suit different audiences. Maybe it’s because I live in West Virginia (I didn’t vote for our current president–I’m not a fundamentalist, libertarian, conservative, or Republican), but I see the effect of stay-at-home orders as devastating to the working class and poor. All of my middle-class friends are comfortable with working on-line, visiting with friends on-line, careful visits with safe family members. It’s easy for us to come down on the side of mandates that hurt the poor, working and non-working, and may leave many of them and their children homeless. I’m concerned about the death rate more than about the infection rate (of course I understand they’re related–I’m talking about the strength of the relationship); and as far as I can tell the rate is still pretty much all over the place, ranging from less than 1% to about 6% of infected populations tested. I think we’ve paid too little attention to methods of protecting people who are especially vulnerable without lock-downs and closings. Especially as we haven’t done an especially good job at protecting some racial or ethnic groups with them. Too, it seems likely that many young people (and alienated older people) would be more likely to comply with recommendations than they do to orders. This nation has never believed in “safety first” or we would have never had coal mines, which by their nature and even with care, were hazardous places to work. We wouldn’t in fact have any hazardous jobs if we truly believed, as one medical professional said on television, that “one death is too many,” we would be a different nation. I’m glad to see someone offering education and guidance as an alternative to forced closings and lockdowns. As a postscript, to the author’s metaphor of sex education, I’d add education about tobacco use as a successful example of decreasing deaths and illness from smoking.
Truly valuable points, Edwina, and phenomenal writing!
There would be no need for lockdowns if everyone followed your advice, which matches what the CDC and most local health departments have been pleading for since spring. The problem is many people are disregarding these commonsense ways to avoid a contagious airborne virus. The lock down was only necessary because the prevalence of disease was about to overwhelm the capacity of large city medical centers to care for the victims.
Unfortunately, we are approaching those levels of infection in smaller cities and towns throughout the country, despite the ubiquitnous of the messages about responsible social behavior.
Thanks for the comment Michael. I agree that the problem is that “many people are disregarding these commonsense ways” to avoid this virus. I believe focusing as much on “what can be done safely” as “what not to do” (i.e. no non-essential activities, don’t go within 6 ft of others) would help people socialize in a safer way. Also, some level of public enforcement and encouragement for safe behaviors are necessary.
The notion that we haven’t been educating people about how to socialize safely strikes me as odd. I think there’s plenty of that information going around and that we’ve been doing that.
The larger issue in my mind is that aside from people who are ignoring warnings (because there’s nothing you can do about those people), there are large swaths of people who don’t understand the guidelines (a health literacy issue) and we haven’t done enough to use simple language to convey the guidance required (a language and cultural issue).
There is also the frequency of messaging, the medium used to deliver the message and the cohesiveness from all levels of government on the actual message that are contributing to the problem.
But, to me, teaching people how to socialize safely is not the issue.
Rohit, I agree with you that many people don’t understand the guideline, which is often not in a simple language, and that the issues with the frequency and medium of messaging. In my opinion, information does not equal education. In order for people to understand and internalize Covid-19 related guidelines, whether about masks, physical distancing, and what is high risk and what is not, paying attention to the level of details that you mentioned is critical.
that’s wishful thinking that works only on paper.
Of course, if everyone would follow good public health safety practices like social distancing, mask wearing, washing/disinfecting hands frequently, we could all live an almost normal life. However, you need just a few not complying to make the whole process in vain. And in US, those few are indeed a lot. And couldn’t be more the opposite of like Japanese respectful culture.
Do you think there are more than just a few not complying in Japan? I mean infections have been surging and many, especially the younger, who are responsible for most of the increase, being very careless.
I see people outside–say along the Tamagawa River—on weekends not respecting social distancing at all and many not wearing masks. I see people wearing masks improperly with their nose hanging out. There are people going to small bars where social distancing is impossible—the 3Cs? There are those interviewed on TV as to why they are taking such risks (face blurred of course) darn near every day it seems.
I see people with no choice but ride extremely crowded trains packed very close together where close contact is unavoidable. Fortunately, with the recent surge, some train lines have decided to crack a window or two occasionally to provide ventilation. Some companies even have rule about opening windows in the building every 30 minutes for ventilation. Too bad many of those windows are permanently closed.
And masks. Masks have been worn on Japan (and other east Asian countries) for decades in the belief that they protect wearers from viruses. Another big reason for wearing them is the pollen allergies caused by the artificially high number of cedar trees by over-planted for commercial purposes decades ago. So it was no problem to convince most Japanese to wear them to reduce the spread of coronavirus. Folks from western countries would—up until this year—react with disgust at the weirdness of wearing them. I heard those kinds of remarks again and again, and you can still find comments like them on the internet from the past. “Creepy masks.” How about the latest masks that are becoming popular here? The sort of plastic half face shields that cover ones chin and mouth leaving a huge gap all around. Is there evidence those are effective? Respectful?
Japan and most of its people took the virus seriously from the start. China is not that far away and viruses from there have hit Japan harder than the US on the past. We had a cruise ship full of passengers, many who became infected, stranded in Yokohama. We knew it was serious. It was indeed the opposite in the US. Initially, journalists, politicians, even physicians often tried to “calm” people by claiming it was not as dangerous as the flu. One could read news reports from the US and wonder if Japan was not over-reacting. The idea of the flu being a bigger danger in the US even reached Japan, with people sometimes asking me about the serious flu epidemic there that was even worse than the coronavirus threat.
It may shock some Americans, but I occasionally do see people not wearing masks indoors or on trains or in crowded places. Some are Japanese. Some are western looking people. Quite often those western looking people are not speaking English or Japanese, but one or another of the European languages.