Politics

eight methods to exit and keep protected throughout the coronavirus pandemic

Americans have gotten tired of staying inside. As the coronavirus pandemic has continued for months and summer has kicked off, the number of people consistently practicing social distancing has steadily declined, according to Gallup’s surveys. Especially with the July Fourth weekend approaching, people are bound to go out more to celebrate.

At the beginning of the pandemic, experts’ guidance was more absolute: As much as possible, stay home and avoid interacting with anyone you don’t live with. More recently, with a vaccine likely still months or years away, many experts have advocated for a new approach to get people to stay safe during the coronavirus pandemic — one based on harm reduction.

It might be better for people to stay home all the time, but given that many can’t or won’t, giving them advice on how to reduce the harm to them and others is better than insisting on the ideal.

Julia Marcus, an infectious disease epidemiologist at Harvard, compared the choice to preaching abstinence versus advising on safe sex during the worst days of the HIV/AIDS epidemic: Completely avoiding sex would keep someone safe from HIV, but given that most people won’t do that, it’s better to give them the tools to practice sex as safely as possible.

“There’s been a polarization between two purported options of staying home indefinitely … versus going back to business as usual,” Marcus told me. “The idea of harm reduction gives us a way of thinking about risk as a continuum and thinking about the middle ground between those two options.”

The safest thing anyone can do in the middle of the Covid-19 outbreak is still the same as it was a few months ago: Stay home as much as possible to avoid catching or spreading the virus until there’s a vaccine or effective treatment, or until the pandemic otherwise ends. That especially applies to people who are sick, who should do all they can to avoid exposing others to the coronavirus.

But lapses will happen. Some people were never able to stay home in the first place; as states begin to reopen, many more will need to leave their homes for their jobs. Others will do so simply because they’re tired of being stuck at home, even if it’s not advisable for their own health or for the public’s.

So I turned to several experts with a question: What can people do to minimize the harm to themselves and others if and when they choose to go out?

Some of the advice reflected the message we’ve already heard for months: Wash your hands. Don’t touch your face. Wear a mask. Avoid shared surfaces and crowded settings, and keep physical distance — at least 6 feet — from people you don’t live with. If you’re 65 or older or have chronic health conditions, you should take all of this advice more seriously.

Amanda Northrop/Vox

Other tips were more novel. For example, if you want to do something outside your home, it’s better to take advantage of the fresh air and do it outdoors rather than indoors when possible. If you want to meet with certain friends or family, consider a pact with them in which you’ll both agree to minimize or eliminate contact with anyone else, to reduce overall exposure for everyone involved.

The most important thing: Avoid indoor spaces that bring you within 6 feet of people from outside your household for long periods. “It is about density. It is about duration of contact,” Cyrus Shahpar, a director at Resolve to Save Lives, told me.

Overall, experts were receptive to applying harm reduction concepts to social distancing. They acknowledged it’s not a perfect analogy to HIV or drug use, because a person who’s having risky sex or using drugs is perceived as largely harming themselves, while people who catch and spread the coronavirus put others at immediate risk too. Still, experts took a pragmatic view toward harm reduction overall.

“It reflects the fact this virus is going to be with us until there’s a vaccine,” Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security, told me. “People are going to come up with their own ways to live with it. That’s going to be different for each person, based on their own risk tolerance.” He added, “It’s important that people be well-informed about what the risks are and how to minimize the risks.”

So here’s how to go out and stay as safe as possible during this coronavirus pandemic. (Vox also has a guide on the risks of specific activities.)

1) Stick to the outdoors

Experts consistently gave one piece of advice for people leaving their homes: If you can do something outdoors instead of indoors, you should do it outdoors.

The coronavirus appears to spread through airborne droplets and droplets that land on surfaces, which people subsequently pick up with their hands. The outdoors mitigates these vectors of spread in several ways.

First, the open air is going to make it harder for airborne droplets to reach other people. Shahpar said there’s a common sense element to this: “Any odor I have from cooking in a kitchen is going to linger longer than if I had it outside. It’s just the nature of it.”

Second, it’s easier to keep distance from others while outside compared to inside.

Visitors at a lookout point in Joshua Tree National Park in California, the day after the park reopened on May 18.Mario Tama/Getty Images

Third, there is some evidence that sunny, warm, and humid weather hurts the coronavirus a bit. Based on the early research so far, heat and UV light appear to kill the virus, while humidity might block airborne droplets from blowing from person to person. The weather isn’t enough to stop the coronavirus — as major Covid-19 outbreaks in sunny and warm Ecuador, Louisiana, Singapore, and now Arizona, Florida, and Texas demonstrate — but it at least seems to help.

The research into coronavirus and the outdoors, while still very early, backs this up, Kelsey Piper explained for Vox:

One study from China (which has not yet been peer-reviewed) examined 318 outbreaks with three or more people across the country. Only one happened outdoors, and only two people got sick: Every outbreak with three or more cases happened indoors. A different study (also not peer-reviewed) in Japan found that “the odds that a primary case transmitted COVID-19 in a closed environment was 18.7 times greater compared to an open-air environment.”

So if you’re having friends over, consider hanging out outside (and keep it to a small group). If you want to eat at a restaurant, look for outdoor seating. If you’re going for a run, go to the park, beach, or streets instead of the gym. Some experts said policymakers could take advantage of the outdoors as well — holding trials outside, or closing off some streets to cars so pedestrians can make better use of them.

“It’s a good year for outdoor dining and outdoor shopping and outdoor all kinds of activities,” Mark McClellan, who previously headed the Centers for Medicare and Medicaid Services and the Food and Drug Administration under President George W. Bush, told me.

The one exception, of course, is your home. As long as it’s just you and the people you live with in there, it’s safe — likely even the safest place during this pandemic if no one inside is sick.

This isn’t to say that the outdoors is totally safe. Being around people you don’t live with will always create some risk during a pandemic. This is about weighing the pros and cons: Does the relatively small risk other people present outdoors outweigh the benefit of getting some time outside of your house? Different people may come to different answers.

But all else held equal, the outdoors is the safest place for activities outside of your home. For some, that’s a reprieve that makes all the other requirements for social distancing a bit more bearable.

Plus, spending time outdoors can be good for you on its own.

2) Follow good hygiene practices

You’ve probably heard it a million times already, but it’s worth repeating: Wash your hands frequently, and don’t touch your face. If you’re going to frequently venture far outside your home, that advice is especially pertinent.

“Those are harm reduction aspects have been built in already to the messaging that we’ve seen,” Saskia Popescu, an infectious disease epidemiologist, told me.

Studies have shown the virus can survive on different surfaces for hours or days at a time. If you touch those surfaces, then touch your face, you could get the virus in your eyes, nose, or mouth — and soon, you might be infected.

By now, there are plenty of guides out there about how to avoid touching your face and how to wash your hands. For face-touching, the big thing is awareness. Until you break the habit, you’re going to have to dedicate headspace to your face and avoiding touching it. (I touched my face three times just typing this paragraph, so, yes, it’s going to take effort.)

For hand-washing, do it frequently — before, during, and after you go out. Soap and water work great; wash for 20 seconds, and don’t forget the back of your hands, your fingertips, your thumbs, and your wrists. If you don’t have access to soap and water, hand sanitizer with at least 60 percent alcohol content works too.

Yes, good hygiene can be tedious, and we’re all tired of hearing about it over and over. But it works. If you want to minimize risk to yourself and others, you should do it.

3) Wear a mask

After some mixed messaging from federal officials early on in the Covid-19 outbreak, there is widespread consensus that people should wear masks when they go out — a surgical or medical mask if they have one, a cloth one if they don’t.

The Centers for Disease Control and Prevention recommends masks “in public settings where other social distancing measures are difficult to maintain (e.g., grocery stores and pharmacies), especially in areas of significant community-based transmission.” But other experts — and, in some cases, government mandates — go further, saying you should wear a mask in just about any setting outside your home as long as the pandemic continues.

The primary reason for a mask is to stop transmission from the wearer to others, particularly from people who are infected but asymptomatic and therefore might not even know they’re infected. If you wear a mask, you’re less likely to spray virus-containing droplets on surfaces or other people when you breathe, talk, sing, laugh, sigh, snort, cough, sneeze, and whatever else you might do with your mouth and nose.

A mask also likely offers some protection to you by creating a physical barrier to droplets from others in front of your mouth and nose (at least if you’re wearing it properly — make sure that it’s covering both).

The initial research on masks wasn’t great, but it’s getting stronger. Several recent studies found masks alone reduce transmission. Some experts hypothesize — and early research suggests — that masks played a significant role in containing Covid-19 outbreaks in several Asian countries where their use is widespread, like South Korea and Japan.

It can still be difficult, depending on where you live, to find medical masks. But there are cloth alternatives you can make at home. The CDC has an extensive tutorial. And here’s one from the US surgeon general:

There are also things you can do to help others wear masks. For example, if you’re hosting a large event or even throwing a party — not advisable, but it will happen — offer masks to the people attending.

When wearing a mask, don’t fidget with it — that would be touching your face — and avoid taking it off until you’re back home. Throw away disposable masks once they’re used, and wash reusable masks after you use them.

Masks are not an excuse to ease off on other hygiene practices. In fact, you want to wash your hands before and after taking off a mask — before, to avoid getting anything on your face and mask, and after, to get rid of anything that was on your mask.

And yes, it’s normal to have a slightly harder time breathing while wearing a mask for a long time. But that discomfort should be weighed against the risk of getting sick or infecting others without a mask.

4) Stay away from crowded settings

One of the common pieces of advice throughout this pandemic has been to keep 6 feet or more away from people you don’t live with, summarized by the catchy but grim slogan “6 feet distance determines our existence.” The closer you are to someone, the likelier they are to shed their coronavirus all over you, and vice versa.

One telling but preliminary study comes from a South Korean call center: The coronavirus spread to 43.5 percent of people working in the close-packed 11th-floor call center. Proximity appeared to play a big role, as this graphic, in which desks marked in blue indicate infection, shows.

A graphic showing the office layout of a South Korean call center and who got infected with Covid-19.

Centers for Disease Control and Prevention

The risk here is close and prolonged contact. A jogger running by you for a couple of seconds isn’t the end of the world. But if you’re within 6 feet of someone else for longer than that — especially for hours — it could be dangerous.

“The two variables we worry about is that distance from another person who might be sick and the time spent with them,” Crystal Watson, senior scholar at the Johns Hopkins Center for Health Security, told me.

This applies to the outdoors, too. While the outdoors are generally safer than the indoors, it’s still a good idea to avoid packed parks or beaches. People who don’t live together just shouldn’t be stacked together for long in any setting.

So if you’re going out to eat, consider skipping the packed restaurant. If you’re going to a park or beach, look for an area without too many people around. If you’re hosting an event, avoid inviting too many people. If you’re meeting up with friends or family, try to stay at least 6 feet away and avoid handshakes, hugs, and kisses.

Part of avoiding crowded spaces is also making these places safer for those who have to be there. For example, public transportation can be pretty packed, but some people need to use it to get to work or the grocery store. If you have other means of transportation and use that instead, you leave more room on the bus or subway for those who don’t have a choice.

You don’t have to do all of this perfectly; in some circumstances, that’s unrealistic. But the better you can do it, the lower the risk.

5) Avoid shared surfaces

If the coronavirus spreads when people pick up virus-containing droplets from different surfaces, one way to minimize that risk is by trying to avoid shared surfaces as much as possible.

So even if you go outdoors, avoid surfaces touched by different people, like swings, slides, or benches — or, at the very least, wipe them down before using them. If you have to use public transportation or go inside a building that isn’t your house, try to minimize how much of the space you touch.

And if you’re meeting with people you don’t live with, try to avoid sharing things — food, drinks, toys, board game pieces, and so on.

That doesn’t mean you have to be paranoid about picking up food or getting various things delivered to you. (As Jen Kates, director of global health and HIV policy at the Kaiser Family Foundation, told me, “I often get asked the question: ‘Can I get takeout?’ I think you can.”)

But it does mean a little caution is warranted, either in terms of avoiding these surfaces or taking steps to clean them before you touch them.

6) Space out trips outside the home as much as possible

Whether you’re leaving your home because you have to for food or work, or you’re going out because you can’t stand the sight of your apartment anymore, one way to minimize risk is to space out all your trips.

With every venture outside, you are putting yourself at risk of contracting the coronavirus in a world that’s still engulfed by a pandemic. The risk calculus, then, is straightforward: Try to limit how often you do this.

“It’s not a good idea to be going out to the store every day,” Kates said. “You want to minimize the amount of times you might expose somebody (to coronavirus) or you might be exposed.”

Customers shop at a supermarket in San Francisco, California, on May 3.Liu Guanguan/China News Service/Getty Images

One way to do this is to make the most out of necessary trips. If you’re going to the store, try to buy as much as you can afford and carry in one go, and plan ahead so you don’t forget something. (Still, be reasonable and conscientious of others; taking a year’s supply of toilet paper is unnecessary and could force others to make more trips when the store runs out and they have to go home empty-handed.)

This applies to social gatherings, too. If you saw friends recently, maybe go a few days or weeks before seeing them or another group of friends. Two weeks would be ideal, since it would match the coronavirus’s possible incubation period.

Similar to avoiding crowded spaces and keeping physical distance, this isn’t something everyone is going to be able to do perfectly. We all sometimes forget things at the store and have to go back earlier than we’d like. But the more spaced out trips outside the home are, the better.

7) Create a “closed circle” with specific friends or family

Especially if you’re single and living alone, these can be pretty lonely days. One solution that some experts have put out there is creating a “closed circle” with a friend or family member, in which two people or a group agree to hang out in person but avoid contact with everyone else.

If you and your closed circle avoid everyone else, you’ll reduce the chances of infecting each other and the rest of the world even if you hang out regularly. And if one of you does get sick, the spread should be limited to a small circle.

As Sigal Samuel explained for Vox, this idea isn’t risk-free, and some experts are opposed to it. There’s a risk that people just don’t stick to the pact, putting the whole circle at risk of infection — maybe even at a higher risk if it creates a false sense of security and people in the circle act recklessly toward each other. But even if everyone follows the pact as best as possible, the concept expands your social network and, therefore, your risk of infection — from not only those in the circle, but anyone people in the circle have to interact with at the grocery store, pharmacy, work, or any other setting.

But that’s harm reduction. The closed circle may not eliminate harm, but it does minimize it.

Consider the alternatives. If people are going to interact with their friends and family, but they do it without a closed circle, that’s inherently worse than having a pact, even one that’s not perfectly followed.

“Is there a way to make it that, 100 percent, everyone is abiding by those standards? No,” Kates said. “But it’s a harm reduction approach.”

The risk that a closed circle doesn’t work as planned also has to be weighed with the significant risk of loneliness. As Samuel noted, “A meta-review of 70 studies found that loneliness increases your risk of premature mortality by 26 percent. Some experts say it’s as bad for your longevity as smoking. We know that it actually hurts our white blood cells.” We can try to alleviate that loneliness with Skype, Zoom, or phone calls — but, for some people, that’s not going to be enough.

“There are people suffering in isolation,” Marcus said. “In order to sustain this for months or even years, we have to think about how we can connect with others in a way that keeps risk as low as possible, that allows people to feel like they’re living their lives.”

It’s also possible to mitigate the risk of breaches in a closed circle by following the other tips on this list: Even when hanging out with your closed circle, go outside when possible, wear a mask, follow good hygiene, and keep physical distance from each other. A closed circle doesn’t have to be a license for much riskier behavior; it can just be an extra layer of protection if you want to regularly see other humans in person.

8) If you’re in an especially at-risk group, be extra careful

Some people are more vulnerable to the coronavirus. Certain chronic conditions, including asthma, diabetes, liver disease, and obesity, appear to heighten the risk of complications and death due to Covid-19. Those who are older, especially 65 and up, are at higher risk too.

It’s not fair, but it means that those who are at greater risk should be extra careful.

Andrea Tamkin wishes her mother Ruth Tamkin a happy Mothers Day in Boston, Massachusetts, on May 8. Ruth is in a nursing home that, for client safety, doesn’t allow visitors to enter.John Tlumacki/The Boston Globe/Getty Images

One way experts described this concept: If you fall into one of these at-risk groups, follow the advice on this list but take it to an extra level. If most people typically wash their hands seven times a day, someone in an at-risk group should do it 14 times. If others should stay 6 feet from people, those in at-risk groups should try 10 feet. If the typical person should minimize trips to the store to once a week, people in at-risk groups should try to minimize trips to once every two weeks. And so on.

The safest thing for older people and those with chronic conditions is, like everyone else, to stay home as much as possible. But just like everyone else, this isn’t going to be feasible for some people all day every day, or at least something everyone will be willing to do for weeks or months on end.

“People will take risks, whether we like it or not,” Marcus argued. “The best thing we can do is give them strategies to reduce harm in those situations. If we don’t do that, we’re missing an opportunity.”

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