Social distancing in the coronavirus pandemic — maintaining public health by staying apart

Confusion exists 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 wish to provide my opinion below based on the best information available to me today.

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 the coronavirus. We are only about 10 to 14 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 rapidly 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” of this pandemic.

How the curve of the #coronavirus outbreak could be flattened. Important read from @HelenBranswell https://t.co/qF35LxplRR pic.twitter.com/yh0pEI1UEJ
— Rick Berke (@rickberke) March 11, 2020

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 and physically distance each other immediately. On a regular day, there are 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 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 in various articles published recently. These statistical models 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 canceled?

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 local, state, and national leaders to close all schools and public spaces, cancel public gatherings, and enact eight key policy changes now.

A local, town-by-town response won’t have the adequate needed effect. We need a comprehensive statewide, multi-sector approach in these trying times. We need to push our elected leaders to enact statewide closures of schools for up to two months. We also need to push for the following eight common-sense policy changes to stem the tide.

We need to limit public gathering size — the smaller the better. Certainly any public or private social, faith-based, or community gatherings over 25 people need to be canceled, perhaps even at lower numbers.
We should sharply increase funds for emergency preparedness and make widening Covid-19 testing capacity an immediate and top priority.
We need to ask state leaders to work with both the public and private sectors to have all non-essential staff work from home. For those sectors or businesses who cannot accommodate that recommendation, they should enact staggered staff work shifts with adequate physical spacing to reduce the risk of transmission.
We must ask legislators to pass widespread, guaranteed paid leave during this crisis to ensure that workers who are out won’t just drain sick leave, vacation benefits, or worse, suffer financial hardship by being unable to work.
While businesses must do their part above to support workers, they also need state help (especially if they are small) in the form of favorable short-term small business loans, tax credits, and delayed tax day filings to get through this upheaval.
Extending unemployment benefits can help to mitigate the impact of reduced work shifts and job availability.
Commercial health insurers should agree to waive co-payments for Covid-19 testing and treatment, reducing barriers to accessing care. MassHealth should temporarily expand coverage to all remaining uninsured people during this time in order to enable testing and care for all.
Health care provider groups need to rethink the delivery of ambulatory care services including primary and specialty care. Telehealth and virtual care services need to be quickly ramped up with in-person visits kept to a minimum, and state and commercial insurers should agree to equilibrate reimbursement for those virtual services with in-person visits. Drive-through ambulatory testing centers should be established as points of care for rapid diagnostic testing, so that patients can avoid the ER when possible and have access to safe testing sites instead of ambulatory care clinics.

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 needs, and older adolescents (including homebound college-aged individuals) used to frequent in-person socializing. 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 the coronavirus take four to five days to manifest themselves. Someone who comes over looking well can transmit the virus. Sharing food is particularly risky — and shouldn’t be done outside of family or usual housemates

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, 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, China). 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 physical distance.

Exercise, take walks or runs, and stay connected through phone, video, and social media. When you are 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 the 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. Play 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, do 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). Schedule regular “virtual” coffees and reconnect with old friends. Physical distancing doesn’t need to mean social isolation — we may find that we have the time and virtual space to build or improve relationships in new ways.

We need to find alternate ways to reduce social isolation within our communities through virtual means instead of in-person visits. Schedule regular “virtual” coffees and reconnect with old friends. Physical distancing doesn’t need to mean social isolation — we may find that we have the time and virtual space to build or improve relationships in new way. There can be an often under-appreciated solace to video calls with grandparents, good friends, and neighbors as we process together this temporary physical separation. And faith-based communities can find new and meaningful ways through technology to share beautiful ritual, physically apart but spiritually together.

4. Reduce the frequency of going to stores, restaurants, and coffee shops for now.

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 (spread out at least six feet apart) 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 as best as you can. If you have questions about whether you qualify or should get a Covid-19 test, you can call your primary care team and/or consider calling the Massachusetts Department of Public Health (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. And while it may involve short-term sacrifice, the alternative may be even more bleak. In Italy, the health system is struggling to function and health workers are overwhelmed with sick patients, making impossible choices with limited resources available. Mandatory closures of all businesses (except grocery stores and pharmacies) and public transportation in tandem with restricting people’s movement is functionally quarantining large groups in place.

We can try to change the trajectory here in Massachusetts. 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.

Dr. Asaf Bitton is executive director of Ariadne Labs in Boston. This is an updated column that he wrote in Medium.