Two months ago, I interviewed Asaf Bitton, a primary-care physician and public-health researcher who directs the Ariadne Labs at Brigham and Women’s Hospital and Harvard’s School of Public Health, about the guidelines he had compiled on how to best practice social distancing. These guidelines were released on March 13th, just as states were issuing shelter-in-place orders and Americans were wondering how they should perform basic activities, like daily walks and grocery runs.
Now, with businesses beginning to open up, and activity set to increase, I spoke by phone with Bitton again. I wanted to know what scientists had learned over the past few months about best practices for social distancing, what activities people should feel more comfortable doing, and where people should exercise more caution. In our conversation, which has been edited for length and clarity, we discussed why public-health officials have changed the way they think about masks, the risks of socializing indoors, and the problem of public bathrooms.
What have we learned about the best social-distancing practices in the last ten weeks?
I think that we’ve learned from a number of studies that social distancing, when practiced en masse and consistently, actually can work to drive down the rate of growth of cases. This has gone from theoretical economic-modelling literature to a lot better epidemiological data. The practices that work are really the practices that reduce the ability of respiratory droplets to easily travel to other people. So that means that we’ve learned that it’s not just the distance quotient or equation. In fact, we’ve learned that sneezes and coughs can actually amplify beyond the six feet, but, in fact, that masks are really effective. Ventilation is really important. And the time interval that separates people from touching the same objects is important. So making sure that we’re not just washing hands but also not touching the same objects, especially indoor objects, is the hallmark of effective distancing strategies.
I’ve heard people say, well, six feet is not necessarily the exact distance. Is there an argument that you need to sell social distancing to the public, and that six feet is kind of a handy, helpful way of thinking about it?
I think it’s helpful, but it’s not fully complete. It has an idiosyncratic history that comes from both old literature on the spread of meningitis among kids in a Texas classroom, in the early nineteen-eighties, and some old studies by the military on sneezing, as well as how people got SARS from a flight between Hong Kong and Beijing twenty years ago. I think the important thing that people need to remember is the idea that it’s at least six feet. And what I mean by that is, there’s no evidence that anything less than six feet is at all safe. And there is evidence that, again, when people who are uncovered have big coughs or sneezes, they can sneeze twenty feet or more.
So the key, to me, since “six feet” is already in the lexicon, is not to debate six or eight or twelve, when the science isn’t really perfect about that and there’s so much individual variation. Let’s have a minimum. And let’s extend our knowledge by saying it’s at least six feet. And since it may be more, be wary of that, especially in indoor environments. Understand that masks can really help, I think, a lot more than we understood at first with this condition, because of their containment capacity. And understand, from some of these super-spreader events, like the choir in Washington or the religious service in California, that even people singing or talking for long periods of time in an enclosed space can be risky. And so it’s both distance and density, and then time exposure. So six feet is a good starting point, but it’s not the end of the discussion.
We didn’t talk about masks two months ago, but from what you’re saying it seems that they’re extremely helpful, primarily because they keep people from spreading, rather than preventing people from breathing it in. Is that correct?
Exactly. We were, I think, way too focussed on the protective properties of the particular material in the mask as constructed, and whether it can protect you when you enter a zone of known infection. So we were thinking about masks, really, in too much of a biomedical context. Is this mask safe enough for a health-care worker or a relative to step into a zone with someone who has an infection?
Now, that’s an important use case. But now that we’ve inverted our thinking, or at least expanded it, to think more from a public-health or community perspective, we’ve actually learned to think of masks from the inside out. And this is why, even a hundred years ago, they were so popular and actually sternly advised by public-health authorities during the great influenza outbreak. And so if everyone’s wearing a mask, even if each individual mask has holes, you have that protection because we’re containing it. So that’s been a major extension of our imagination or understanding of this dynamic.
So I assume you would say that we should all be wearing masks if we do something like go to a beach, or go to a hiking trail, even if we’re six feet apart from everyone while we’re there.
I do. People love to be Talmudic about this: “If I’m walking in the woods, and there’s no one around me, not even a bear, can I take the mask off?” And you know what? Yes. Fine. If you cannot see another person around you, and it’s in a well-ventilated, outdoor area, fine, I would suppose that you don’t need a mask. But if you are going to a crowded beach, a crowded park, walking down the street where people are talking and breathing and coughing and sneezing, you should wear a mask.
Would you say that the conventional wisdom in the last couple months, as you have hinted at, is moving more toward concern about indoor areas and less concern about outdoor spaces, even with people?
Yes. I think that what we’ve learned by understanding some of these super-spreading events, but also by carefully monitoring what’s happened to our health-care-worker population, is that by far the riskier interactions happen in densely packed indoor spaces, where there’s poor air circulation and where there are more surfaces that are coming in contact with multiple people. So the biker who’s whizzing past you, even if they’re breathing heavily—if you’re in an outdoor environment with wind and air, you need a certain density of viral particles to effectively transmit the disease. And while a person breathing heavily on a bike zooming past you might exhale more air, they’re doing it over a huge space and they’re doing it in a way that is so transient that it’s unlikely to affect you.
We’ve learned more about surfaces, and the fact that this can stay around on metal or plastic for three hours. And so it still probably makes sense to not climb all over the same playground structures, though that’s not where the majority of transmission has happened. The majority of transmission is happening in indoor, poorly ventilated environments commonly used by multiple people who are coming in and out. And I think that’s where the focus of our transmission reduction should be.
People in my own life seem more than willing to go to a hiking trail or a not very crowded beach, or to take walks down streets where there are people, but they often seem uncomfortable about going to someone’s backyard and sitting eight feet apart. Is that rational? How do you think about something like that?
I definitely relate to that question, and have thought about it. I think that it doesn’t fully make sense, if you’re maintaining distance and have a mask on, to not be able to be outside in your back yard, as opposed to being outside in a park or on the street at the same level of distance. The only complexity that I can think of that the back yard offers is: Are you sitting down on that deck chair or piece of furniture that a bunch of other people from the household or from other households just sat on, and did someone just sneeze and wipe their hand on it? So there are, admittedly, a set of extended possibilities. But maybe the answer, if you’re really wanting to be safe, is to go to someone’s backyard and maybe sit on the grass, if they have grass, or don’t sit on common furniture. But I don’t see any reason why—as long as you’re not congregating in super dense areas that don’t have good ventilation—that’s any different from meeting them outside at eight feet.
And in both cases you think that masks are necessary?
I do.
What is your current thinking about activities that will not follow guidelines for social distance, but that can be done with masks? I’m thinking of something like getting a haircut, when the person cutting your hair is wearing a mask and you’re wearing a mask, and presumably you see the chair being wiped down, and whatever else needs to be done. The scissors are dipped in a disinfectant solution.
The answer is really contextual, and what I mean by that is that the decision on whether it’s safe enough to do all of these activities of daily living really needs to be put into the context of where your community and your state is in the course of the epidemic. So if you’re in a state like Montana, with very few cases being reported daily, and no uptick, and you have hospital-surge capacity, and you have decreasing numbers of people being hospitalized, and you have good testing capacity and low rates of positive tests, then I think you’re further along in the arc toward more full reopening. In that case, with masks and all those hygienic measures that you mentioned, it would make sense to consider a haircut.
But if you’re in a state that has rising cases, or thirty-five-per-cent test positivity—which implies that you’re not testing enough, so you really don’t know the number of your cases—or you’re having surging numbers in your hospitals, then I would say that doesn’t sound like a really good idea to have open barbershops, where, by definition, you’re interacting with people within two or three feet and breathing on each other.
Are there things that haven’t been allowed during the last two months that you would now feel comfortable doing? And what do you think other people should feel comfortable doing?
Within Massachusetts [which entered the first phase of reopening on Monday, May 18th], the first phase is pretty restricted. It’s really about manufacturing, construction, and some community-health and ambulatory-health openings, which I believe we all think are sensible. It’s the week after that is where your question really may lie. So, in the second week, car washes and pet grooming are going to open up. Retail can open up for curbside pickup and delivery. I think car washes and pet grooming make sense, as long as the pet groomers wear a mask. There have been cat transmissions documented, and the C.D.C. says dogs may get it, too. It’s really the hair salons, which are possibly reopening in this next week, that make me a little nervous—again, because of that reduced space between people.
Massachusetts has said as well that houses of worship can reopen at up to forty per cent of their previous capacity. That one, I think, has me and a number of public-health folks concerned. Now, there is an advisement that whenever possible houses of worship should hold their services outside, which I think makes a ton of sense, because it certainly reduces risk of transmission. But given what we know about singing and extended periods of time together, even at six feet apart, I’m nervous. And, in fact, our synagogue is not reopening this weekend, even though it technically could, in part because that seems like a little bit of a bridge too far right now with the number of cases we have in Massachusetts.
And for you personally?
Yeah, there is one thing. I feel that, with adequate social distancing, I will look forward to going to a beach.
There was a very interesting article in the Washington Post on Tuesday, May 18th, saying that one problem for businesses, whether they’re theatres or stadiums or restaurants, is that people are not going to feel comfortable using the bathroom. And everything you’ve said today, with the combination of warnings on small enclosed spaces and surfaces, makes me think that’s a really tricky issue.
Yeah. I think bathrooms are a bit of a conundrum, especially around this wave of businesses reopening. But, also, I think one of the thorny challenges is schools reopening. Listen, it’s pretty clear that you can shed the coronavirus in stool and probably urine. And, in fact, there’s some community-monitoring epidemiological surveys that are monitoring the spread of the coronavirus in communities by testing sewer water. So we know that there’s theoretical transmission there. Plus it’s just that sort of enclosed space.
I’ll add two more things. In male bathrooms, there’s urinal proximity, which is incredibly close, and there’s sink proximity in all bathrooms. So that’s one issue. The second issue is the hand dryers. They totally circulate air particles in an enclosed space at high speeds, and that’s concerning as well. One thing about bathrooms in particular, at least—can they move back to paper towels for now? Can you put tape across every other urinal and every other sink? At least something to make this tenable. I know that article referenced bathroom monitors. But, yeah, this is going to be one of the thornier issues in opening up safely.
You said that, generally, ventilation is good, but that air dryers blowing things around is bad. Do we have any sense of what wind would mean for something like the coronavirus?
You mean wind outside?
Yeah.
Well, the issue is the volume of space over which the air currents happen. So, outside, particles get spread very widely, very quickly, and get blown around. The air dryer can blast within a much tinier space, and bathrooms often don’t have the best ventilation. They can blast a cough or a sneeze or something like that across the bathroom. Now, do I have Grade A evidence of this? No. This is mostly conjecture and theoretical. But it’s one of the reasons why bathrooms, I think, make public-health folks a bit nervous.
Would you eat at an outdoor restaurant where you trusted the management?
In a community like mine, where we have high case rates, I’m not yet there for restaurants. But as cases continue to fall, I’ll tell you what, I would eat at an outdoor restaurant way before I would eat at an indoor restaurant.
Is there anything else that you’ve been thinking about in terms of social distancing in the last couple of months?
The linked ideas of stamina and trust. Social distancing is hard, and it just takes people out of their comfort zone. It’s annoying. Masks are annoying. Having to think about all these things is frustrating, and I get that people want to get back to their way of doing things. In order to maintain stamina, we have to build and maintain trust. And trust is, I think, one of the key ingredients to understanding whether or not we will be successful as a country, and as a state, and as a community in doing this.
There’s been a false dichotomy between people in the business-reopening camp and people in the health camp. As if either side doesn’t want the other. What I have told my friends in the business and economic communities is that you need trust in order to reopen your economy. And just because you reopen your business doesn’t mean that it’s there. You can’t declare trust by fiat. You have to build it. People have to have the sense that going to your place of business, resuming their daily life, will not entail an undue, overwhelming risk for them or their families. The only way to do that is to have reasonable and sensible and approachable policies—that enough people maintain the masks, the hygiene, the distancing, to make it possible for us to actually resume our economic lives. And so there’s a dialogue there that is really important.
A Guide to the Coronavirus
- Twenty-four hours at the epicenter of the pandemic: nearly fifty New Yorker writers and photographers fanned out to document life in New York City on April 15th.
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- The coronavirus is likely to spread for more than a year before a vaccine is widely available.
- How to practice social distancing, from responding to a sick housemate to the pros and cons of ordering food.
- The long crusade of Dr. Anthony Fauci, the infectious-disease expert pinned between Donald Trump and the American people.
- What to read, watch, cook, and listen to under quarantine.
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