By Isaac Chotiner
In order to get some tips on how we should all be going about our daily lives, I spoke by phone with Asaf Bitton, a primary-care physician, public-health researcher, and the director of the Ariadne Labs, at Brigham and Women’s Hospital and the Harvard T. H. Chan School of Public Health. He has produced a handy sheet outlining the best social-distancing practices, and most of my questions for him were about how to follow them. In our conversation, which has been edited for length and clarity, we discussed what to do when you go outside, how often to shower, the importance of walks, how to respond if someone you are sheltering with gets sick, the pros and cons of ordering food, and the unsung heroes at American medical facilities.
What has been the biggest thing that you think people do not understand, or have misunderstood, about social distancing?
The fact that there is an incredible need for speed. We need to do it now and yesterday and not next week. It was deflating and disconcerting to, on the one hand, finally see state, local, and some federal response over the last five days, coupled with images of bars being filled to capacity on Saturday night across cities, and huge lines with a crunch of people at airports that took in international travellers. That was a disconcerting incongruity.
What about in terms of how people are socially distancing? When you talk to people in your own life, is there something they seem to not understand about it?
Yeah. The piece that I wrote that got some traction—and I have to give credit to my wife, Liz—really came out of a huge number of people calling and asking, “If our school is closed, we can still do play dates, right?” Or “Let’s have a six-family picnic in the park,” or “How about a sleepover with only four kids?” That is pretty much the opposite of social distancing. Social distancing isn’t some external concept that applies only to work and school. Social distancing is really extreme. It is a concept that disconnects us physically from each other. It profoundly reorients our daily life habits. And it is very hard. We have all these built-in human needs and desires because we are social creatures who connect with each other, and I think one of the profound challenges, and one of the ways we will know whether we are meeting this crisis head-on, is whether we can sustain this very unnatural—from a human perspective—physical separateness.
But I want to really emphasize that social distancing is really about that physical separation. It is not—and, in fact, it won’t work if it means—an actual disconnection socially from each other, which would have tremendous, tremendous effects pretty much on everybody, but especially kids and the elderly and other vulnerable populations.
You write, “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 three days, and these structures aren't getting regularly cleaned.” Can you discuss this more? There is a lot of fear about the coronavirus living on surfaces. Does going outside at all increase the risk?
Going outside in and of itself doesn’t increase the risk. It is really proximity to other human beings, and specifically to their secretions—their sneezes and droplets. So the recommendation is to please go outside if you can. Please take walks, please bike, with a helmet. Interact with your family members outside. But really the key is don’t interact with people outside of your home unit—whoever you are already in close contact with. The C.D.C. is recommending maintaining a distance of six feet, because that is as far as they can tell droplets can travel. And don’t touch other people.
And in terms of playground surfaces and sitting on park benches, it sounds extreme, but we do know that it lives on surfaces for a long time—some studies have found nine days, some studies have found three days—and we don’t clean those surfaces regularly. You will want to not touch those surfaces.
But the key thing is that you are going to want to go outside, and I am concerned that people are misconstruing social distancing as a recommendation to not get fresh air. And I don’t think that is healthy for people. It is really a matter of maintaining as much personal space as possible.
You write, “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.” How do you weigh this? If you get takeout, there is a whole supply chain where people could be interacting. Should people not do it at all?
Here is where I stand on this. I think that, if a person is really trying to minimize their risk—like, let’s say they are older, or have a respiratory or cardiovascular condition, and they’re trying to minimize all possible risks—then not taking out from restaurants and minimizing that chain of people touching your food might be a good idea. What I am saying is it is not standard practice, but there have been no public-health guidelines for restaurants that remain open to basically have all of their chefs and cooks and people who handle the food wear masks. And so, given the fact that that is not a guidance, there is at least a theoretical, if not probable or likely, somewhat increased risk of transmission from food delivery. I am also a realist and a pragmatist, and I get that, especially in dense urban areas, it is not practical for everybody to cook every meal on their own. And so this is where we have to make our best guess and judgment about that titration of risk and benefit. It’s not about doing everything a hundred per cent all the time. It’s about doing as much as you possibly can and contributing your own personal discomfort or inconvenience to protect yourself and to protect others.
One thing I have been saying, and maybe this is wrong, since I am not a doctor, is that this is not binary. It isn’t that you have been exposed to the virus or not, and if not, who cares. This is about risk mitigation, and, if you do ninety-eight per cent of the smart things, that is better than two per cent. Not everyone will be at a hundred per cent. We are human. But we have to get as close as we can.
All of the infectious-disease modelling would suggest that something is better than nothing, and a lot of somethings are better than fewer nothings. In some ways, this is akin to voting. In a lot of states and cities, especially ones with predominant parties, people say, “Well, what does my vote count?” If everyone thought that way, we would have a more dysfunctional democracy. Your vote does count. A couple of years ago, we had a local town election here where I live decided by one vote. The way I look at it for social distancing is that you never know what your individual action, especially a preventive action, can and will do. It is very hard to quantify a negative of something bad not happening.
But we do have good evidence of what doing nothing will cause to occur. That has become really stark. There are curves and numbers, but you can look at that video that came out from Northern Italy, where, in the newspaper L’Eco di Bergamo, on February 9, 2020, the obituary section was about as long as usual, a page and a half. On March 13th, the obituary section was ten pages long. That is ten pages of people’s real lives affected and ended by this thing. We need to drive home the idea that this is not some fanciful or theoretical social construct. This is really a reality, and we all have a role to play in mitigating worse spreads.
What should people do as soon as they get home? Should they wear certain clothes in and certain clothes out?
Like if they go to the grocery store?
Or even take a walk.
I think there is a distinction. If you take a walk in an open, airy park environment or down a not-too-crowded street, I don’t think you need to rip off your clothes and jump in the shower. If you had contact with anybody within your personal radius of space, or anyone bumped into you, or you were in a crowded environment like a grocery store or pharmacy, and you had to touch grocery carts and credit-card pads, you should immediately wash your hands for thirty seconds. By the way, people should look at videos for how to wash hands. This is a nerdy but important thing. They teach us this in medical school. It’s not just keeping your hands in water with a little soap. There is a method. And there are some great videos.
Would you mind sending me one?
How often would you recommend showering?
Normal, if you are not going out a lot. One thing that comes to mind is if you are going to go out, maybe take a shower after. Can I point to an evidence guideline that supports that? No. But let’s say you are going out for your morning walk. I don’t see how it could hurt to shower after, and perhaps it can help.
What about behavior with the people we are quarantined with? Even though we are exposed to those people, should we still be trying to have less physical contact? Does that matter? Should people sleep in separate beds when possible, or have less sex?
I think that, if you have been living with your family or housemates and have been interconnected for a long time, there is no way to disconnect, especially if you are sharing the same living space. I don’t think we should be sleeping in separate beds right now, with a couple of exceptions. And this is emerging in some of the medical reports right now. We are still trying to figure out what to do if one person in a household is in a high-risk health-care environment, like E.R. physicians and nurses. A lot of people are separating. But I think, if you are not in medical environments or high-risk environments, look, social connection is already challenged so much in these crazy times. Let’s not overly disconnect.
You write, “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 someone in your quarantine feels a little sick, what action would you take? I don’t mean sick with coronavirus symptoms—maybe just a sore throat.
If your space allows—and I am very sensitive that a lot of the guidance today assumes a certain household space and living circumstance that a lot of people don’t have—but if you start to become symptomatic, then separation within the household is recommended, especially if you have been out and about and there is at least a theoretical chance you might have been exposed. So separation within houses when possible, and more intense hand-washing and wiping down shared surfaces, especially kitchen and bathroom, would be recommended. And contact your primary-care team or heath provider, but don’t just walk in. We are quickly flipping to a virtual or telephonic model. You are going to see more and more drive-through testing clinics or centralized cough-and-fever clinics, where the workers have the gowns and protective equipment and are prepared for you. But a lot of small practices are not, and just walking in, particularly with respiratory systems, is not a good idea for you, for other patients, or for the staff.
I do want to say one thing about health-care workers. It has been wonderful that there is an appreciation of especially E.R. and I.C.U. physicians and nurses and the incredible courage and fortitude they are showing. And I also want to acknowledge the people we always forget about that are just as heroic and critical in this battle. There are people like the janitors, the patient-care attendants, the phlebotomists, the lab techs, the people who make food in a hospital, radiology techs. All these people that a hospital doesn’t function without are critical, and are taking risks to do the right thing. They are often underpaid, and work really hard shifts. I just want everyone to remember them and the sacrifices they and their families are making to keep the system going.
Absolutely. Anything else?
I just want to add that I think social distancing resonates as a concept with families and middle-aged and older adults. I worry it is not resonating enough, or that there is an understandable pushback among younger adults, or people whose lives have been upended if they work in the gig economy, or who don’t necessarily relate to the whole social-distancing thing. This is a real opportunity to be a hero by doing almost nothing.
I get that it is uncomfortable, and I want people to get more comfortable being uncomfortable for a while. And I get that it is annoying. Think of your aunt, your grandparents, and people you don’t even know. If you are young and you get it—yeah, you probably will have a mild case, although don’t be so confident of that, because there are certainly a number of sick young folks across the country. The key is that this is really a time to form a new social compact where everyone is giving up a little something. My maternal grandfather fought in the Battle of the Bulge. My grandmother was at home contributing to the war effort and trying to care for a baby. That’s hard. And I get that social distancing will also be hard. But I am always impressed with people’s capacity to respond to adversity.
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