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The Bubble Concept

5/12/2020

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How long do we need to stay socially isolated?


How will we emerge safely?



Note: This summary is focused on coming out of social isolation and does not specifically cover issues in the workplace. However, any safe workplace practices will grow out of the concepts covered here.
How long do we all need to stay socially isolated? How will we emerge safely?
I will define "social isolation" here as “everyone in your immediate household not getting together with others from other households unless you are out of doors, wear masks, and stay 6 feet distant.”
 
I am writing this because our country is grappling with the idea of “reopening” and “relaxing social distancing” and I want to make wise, informed choices and support family, colleagues, and friends in doing the same. So, the last couple of weeks, I tried to put together the best information I could find about these matters. The following is what I have found and the decisions I have made. 
 
I hope the interpretations and links here provide a perspective that helps you make informed decisions for yourselves, your colleagues, and your loved ones. Glad to talk or correspond about this and I welcome additional perspectives and information--especially if you think I have made any mis-statements or errors. 

  • The whole idea of “reopening” is misleading and there is a lot of very poor leadership, conflicting information, and bad information.
I don’t think there is a single issue with coronavirus that does not have complexity and uncertainty attached to it—even getting an idea of the current levels of cases and deaths is complicated; the requirements for adequate testing and contact tracing (both of which are crucial for "reopening") are very complicated. I see very few (if any, though some are closer than others) political leaders communicating this adequately. For more background, see The Futile Search for a Magic Number That Says It's Safe to Reopen (Huffington Post, May 11)

  • Even in states which are handling this crisis relatively well, information can be confusing.
I am relieved to be living in Washington State with a Governor who is taking a deliberate, scientific approach. But, I get confused. The Governor announced a "Safe Start" plan with several phases with an impressive dashboard of measures to trigger moves from phase to phase. When I looked at the phases, I was taken aback because Phase I (which I thought meant right now) says “stay home, stay healthy” but it only indicated this was for “high risk populations.”  I wondered, “Does this mean no one else needs to stay home to stay healthy? Does that mean everyone else can start socializing with friends and family?”
 
I looked closer and saw that Phase I does say “Gatherings—None” so does that mean “No—no extension to friends and family outside of the home”? Then, after a few more clicks on links provided, I realized that we in Washington are currently under a “Stay Home, Stay Healthy” order which means not socializing with family and friends. I didn’t realize that the “Safe Start” plan is different from this order which seems to be a prelude to the Safe Start plan.
 
After a clicking through a few more links, I got tired of trying to find crystal clear messaging about social isolation in Washington State and stopped trying.

  • In frustration with the deluge of confusing and conflicting information, I sometimes wonder “Is all this social isolation really necessary anyway?” But, this questioning is very brief and I always come back to this--You/I really really don’t want to get sick with this virus.  
For one thing, the virus is highly contagious and, even if you get a mild version, you are at substantial risk for spreading it to someone who may die from it.
 
Also, younger adults age 18 – 49 comprise a disturbing percentage of those hospitalized and who die. They can even get strokes. Young children are showing up with bad inflammatory syndromes. The virus can cause long term serious damage, even in those who have not required hospitalization, to the lungs, the heart, the kidneys, the nervous system. We will not know the exact risks of these problems for a long time but these problems are disturbing in their frequency right now.

  • Given all this confusion, what can I/we do to stay safe?—I turned to the "bubble concept"  from New Zealand.  
For guidance, I chose to look at New Zealand because their case rate at the end of April was zero. Yes, I know it is hard to compare across different countries due to so many interacting factors, but they have to be doing something right.
 
“The basic idea behind the bubble concept is to conceive of your socializing not as a matter of the individual but as that of a self-contained household: If you visit the home of a friend, for example, you aren’t the only one put at risk. Your roommates or family members you’re living with, by extension, have been exposed to the risk. Your bubble is that group of people: those you live with and those you closely or regularly interact with.

During the strictest phase of lockdown, most New Zealanders’ bubbles were synonymous with their households. But those living alone could also visit and socialize with another person or couple isolating in the same neighborhood or retirement community as long as neither party interacted with anyone else.”

New Zealand has four Alert levels with level four being the most restrictive. Now they are moving to the more relaxed alert Level 3 in which bubbles are allowed to slowly open by adding one or two more people to their bubble even if they are outside of their household.

The key is that anyone added to the bubble also has a rigorous commitment to interact only with others in the identified bubble. In a scientific study modeling outcomes with bubbles, one of the authors stated “It’s important to take a common-sense approach that factors in the reality of human behavior. A 10-person bubble could work just as well as New Zealand’s conservative version but only if those people live otherwise fully isolated lives. Adding nine people to your network, rather than one or two, increases the chances of someone being contaminated at the store or of someone breaking the agreement and damaging the bubble’s integrity. The success and failure of all this bubble concept depends not only on my actions but also everybody else. It’s really a question of solidarity.”

What makes the bubble idea an effective communication tool is not just its simplicity but also its ability to morph along with changing regulations. As New Zealand now moves into a lighter stage of restrictions, the concept of the bubble is adjusting with it.

In a CNN article on bubbles, an infectious disease specialist stated you have to explicitly lay down the ground rules. "You don't want it to get too big. Just about 10 people or less. Beyond that, the risk is an issue. You'll need people who are trustworthy, so picking people you like just because they're fun at parties might not be a useful metric when picking your group members. One unchecked symptom or one misguided adventure and somebody can get infected with the coronavirus, the virus that causes Covid-19. You're only as safe as the group member least likely to stick to the rules. If one member gets sick, "Consider yourself probably infected."
 
Note: The virus appears to love confined spaces so staying outside is the safest course of action when meeting with others outside your household.
 
What if you need a haircut? What if you are past due for having your dentist check-up? Any step outside of your household bubble is taking on risk. So, whatever you decide, do so with clarity of intention. Here is an article about the do's and don’ts of staying safe from The Atlantic on May 7 that goes into a lot of helpful detail about a large range of possible situations. Just FYI, I cut my own hair last week and I no longer classify a routine dentist check-up as “essential” so I will not be going for a while.

  • In most of the US and even in Washington (see Stat News May 7), it is hard for me to be confident of going beyond the household bubble—well, maybe to the equivalent of New Zealand’s alert level 3 of adding one or two people—but not beyond that.  
For New Zealand, the markers for moving to lower alert levels and larger bubbles is data about the level of community transmission. To move from Alert level 3 to level 2 (i.e. beyond one or two people added) means there is "no community transmission and the disease is contained."

  • It looks like we are going to need to keep up some form of the equivalent of New Zealand’s alert system for a long time—perhaps as long as two years—until there is a vaccine and/or effective therapeutics.  
You can find an excellent summary of three possible scenarios for the future of this pandemic developed by the Center for Infectious Disease Research and Policy in this Stat news report from May 1.
 
You can find excellent details about what it will take in terms of testing and contact tracing for the United States to sustain solidarity and come anywhere close to New Zealand’s success at The 4 Plans to End Social Distancing Explained from Vox.com April 14. What is reassuring to me is that plans from authors with integrity who represent diverse ends of the political spectrum come to the similar conclusions with differences mainly in some of the details.
 
You can find links to three of the plans at the top of this page and here is the plan from the Harvard Center for Ethics as I am so impressed with its comprehensiveness in considering not just public health but also the economy and issues of liberty and social justice. I strongly recommend it.
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