Social distancing is the only thing that is going to save us
Make no mistake: the coronavirus is a deadly virus that has already claimed thousands of lives, and it shows no signs of slowing down. We have nothing in place to combat this yet - no medicines, no vaccines, and no way of treating it. The only thing we can do is what works, and that's social distancing.
The Centers for Disease Control and Prevention (the health protection agency of the United States) has issued guidelines to limit the spread of COVID-19. One of the recommendations is for “social distancing”, which is "a public health practice that aims to prevent sick people from coming in close contact with healthy people in order to reduce opportunities for disease transmission." The Indian government has already put certain measures in place that fall under this recommendation. Sporting events, concerts, and other large public gatherings around the country have been cancelled (with Karnataka even banning parties) but there are individual decisions that can be made too, such as the decision to avoid crowds and/or stay home under a self-imposed lockdown.
The benefits of social distancing are clear. Social distancing stops people from spreading the virus to each other, which means that high-risk populations (the elderly, the very young, pregnant women, the immunocompromised, people who are terminally ill, and other people who suffer from poor immunity and one or more health conditions) are kept safe from being infected by the virus. If people don't get sick, there's less of a burden on healthcare workers and hospitals and hospital equipment. This is called 'flattening the curve', which refers to the likely success of social distancing measures that will help prevent spikes in illness that could overwhelm health care systems.
George Santayana once said, "Those who cannot remember the past are condemned to repeat it." We need to look to instances in our collective human history for the times when social distancing worked. For instance, in 1918, there were a number of reports of influenza outbreaks amongst soldiers who were preparing to deploy to World War I. The city of Philadelphia dismissed these reports and organised a march to support the war effort. 200,000 people lined the roads, cheering as the procession marched by. A mere three days later, every single bed in Philadelphia's 31 hospitals was occupied by sick and dying patients, who were all infected with the Spanish Flu.
They didn't stand a chance. The Spanish Flu was an unusually deadly influenza pandemic, the first of two pandemics involving the H1N1 influenza virus (with the second being the swine flu in 2009). It infected 500 million people around the world, or about 27 per cent of the then world population of between 1.8 and 1.9 billion, including people on isolated Pacific islands and in the Arctic. The death toll is estimated to have been anywhere from 17 million to 50 million, and possibly as high as 100 million, making it one of the deadliest epidemics in human history.
By the end of the week, more than 4500 people were dead in Philadelphia. Alarmed, the authorities closed down the city. But it was too late.
900 miles away, St. Louis was watching. Two days after the first cases of Spanish Flu infected the city's residents, the city swung into action. Schools, universities, playgrounds, offices, courtrooms, and even churches were closed down. Public gatherings were banned. This may seem extreme, but it worked. Flu-related deaths in St. Louis were less than half of the deaths recorded in Philadelphia.
This is what we now call social distancing, which even the World Health Organization has called for in order to stop the spread of the coronavirus. A 2007 PNAS (Proceedings of the National Academy of Sciences) study clearly shows that cities that relentlessly put social distancing measures in place at an early phase of the pandemic — such as closing schools and banning public gatherings — had significantly lower death rates. The key to effective social distancing, is, of course, timing. As in most cases, timing is everything. It is important to put social distancing measures in place before 1 per cent of the population is infected, according to Richard Hatchett, who directed medical preparedness in the Obama White House. Distancing measures are less effective once more people have contracted the virus.
Tom Inglesby, the director of the Johns Hopkins SPH Center for Health Security that works to protect people from epidemics and disasters, had some thoughts about social distancing too. Responding to the Boris Johnson-government's decision to not put any measures in place in the UK, because they claim that 'herd immunity' will kick in once 60 per cent of the population is infected with COVID-19, he tweeted that "It is very alarming to see arguments being made in favor of seeking herd immunity as a national strategy. This seems most concerning in the UK where there are top of government proponents for some kind of strategy with herd immunity as a goal." He went on to clarify. "Terrible risks with that strategy. First – COVID spreading exponentially now in many countries with 1100 cases in UK now (probably substantial undercounting) completely unmitigated exponential growth could see doubling each gen of cases which would put UK at extraordinary numbers in 2 to 3 months (or less if doubling time is faster). Second – while protecting UK elderly should be a top goal, it won't be possible to completely hive them off from society and protect them. They will still contract disease in some numbers if millions of people get this disease in the coming months. Third – It is not just the elderly but also those with variety of underlying med conditions that are higher risk. They will also be at very high risk in this kind of herd immunity strategy. Fourth – not just elderly that die from COVID. Risks highest in 70s+80s, but in China, elsewhere, people in 60s, 50s, 40s, 30s have also died from this disease, even if at much lower rates with decreasing age. Having millions get sick at once will lead to deaths in those ages. We don’t know enough yet about immunity after COVID. There is not confidence yet that infection would provide long lasting durable immunity to COVID 19, or a naturally occurring variant strain that emerges in the future. No guarantee of herd immunity."
The goal of social distancing in the US should be to lower the pace and extent of spread of COVID-19 in any given city or community. If that can happen, then there will be less people with disease, and less people needing hospitalization and ventilators at any one time. 5/x— Tom Inglesby (@T_Inglesby) March 9, 2020
Inglesby referred to an early study (not yet peer-reviewed) that highlights the different experiences of peak coronavirus rates for two Chinese cities. Guangzhou implemented disease control measures early into the outbreak and had significantly lower numbers of hospitalisations from COVID-19 on its peak day than the city of Wuhan, which waited a month into the outbreak before putting measures in place. He also says that there is no perfect approach to social distancing. "It's a big country and we will need partial solutions that fit into different communities. A 75% solution to a social distancing measure may be all that is possible which is a lot better than 0%, or forcing a 100% solution that will fail."
Social distancing, and the options to self-isolate, bring comfort to people like me. I am immunocompromised. I suffer from severe anaemia, which contributes to my weakened immunity. If something is going around, even the whiff of a bug, I am sure to get sick. I've had seven colds in the past year, and three bouts of influenza. I am terrified of getting sick, but worse, I am even more scared of contracting the coronavirus and then bringing it home. My family is high risk; my elderly disabled grandmother is 85. My mother is 61, and not in the best of health.
Earlier assertions that the coronavirus could only be spread by people who were displaying symptoms of the illness are now in question because "asymptomatic transmission likely [plays] an important role in spreading this virus," said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota. According to CNN, "a Massachusetts coronavirus cluster with at least 82 cases was started by people who were not yet showing symptoms, and more than half a dozen studies have shown that people without symptoms are causing substantial amounts of infection."
Bill Gates, the co-chair of the Bill and Melinda Gates Foundation, expressed concern in an article that was published two weeks ago in the New England Journal of Medicine. Calling COVID-19 a 'once-in-a-century pandemic', he wrote about the spread of the disease by people who are not yet displaying symptoms of the disease. "There is also strong evidence that it can be transmitted by people who are just mildly ill or even presymptomatic. That means COVID-19 will be much harder to contain than the Middle East respiratory syndrome or severe acute respiratory syndrome (SARS), which were spread much less efficiently and only by symptomatic people," he wrote.
Italy, which is the second most affected country after China, is in the midst of a nation-wide lockdown. But their instructions to citizens to stay at home came too late for many. There are currently 17,660 people infected with COVID-19 in Italy, with 2651 new cases in just the last 24 hours, and a total of 1266 deaths so far. Italy's healthcare system, one of the best in the world, has been crippled by this pandemic. Exhausted healthcare professionals have spoken about the lack of hospital beds and life-saving equipment for many. “As in any war, we have to choose who to treat and who not.” Il Corriere Della Sera, Italy's leading newspaper, carried that headline on March 9 in an article that spoke about how hospitals in Italy’s north, the epicentre of the coronavirus outbreak in Italy, were overwhelmed and unable to cope with the sick and the dying. Italy's famed healthcare system is on the brink of collapse.
According to the Boston Globe, "An anesthesiologist at a hospital in Bergamo, one of the cities with the most cases of Covid-19, the illness caused by the new coronavirus, told the paper that the intensive care unit was already at capacity, and doctors were being forced to start making difficult triage decisions, admitting people who desperately need mechanical ventilation based on age, life expectancy, and other factors. Just like in wartime."
In conversation with my friend who lives in Como, one of the most achingly beautiful places on the planet, I learned that all of Italy is now a ghost town. "There is nobody on the streets, all the shops are shut, even nobody on Lake Como. Restaurants, cafes, nothing. Most stores are closed too, only food shops and pharmacies are open. We are only allowed to leave one at a time when we need groceries or supplies but otherwise stay inside and don't go out. It's crazy and difficult to keep my children happy but this is the reality and all because we were slow to react! Those first few cases in Milan, that should have been enough. But no. Now this. And god knows when there will be a medicine. It's a very scary time. But I hope the world learns from Italy."
Benjamin Kerr, an evolutionary biologist, tweeted about his concern that only the most vulnerable were being told to socially distance, and said that low-risk individuals also have a large role to play.
To illustrate the point, @ocornejoPopGen and I built a model (SEIR w/ high- & low-risk groups). Because low-risk people are more common, their behavioral change can have *greater* impact on lowering peak number of infections. Ideally, everyone limits interactions, but... [2/8] pic.twitter.com/5s5nxR0mZB— Benjamin Kerr (@evokerr) March 14, 2020
...we shouldn't ignore effects of low-risk individuals changing behavior. Let’s focus on high-risk infected cases (y-axis scaled as before). If only low-risk individuals limit interaction, this has greater impact on *high-risk cases* than if only high-risk individuals do so [3/8] pic.twitter.com/c09TteCeWo— Benjamin Kerr (@evokerr) March 14, 2020
Why such a counter-intuitive result? A nice metaphor for social distancing (HT: @gregggonsalves) involves breaking the propagation of fire in a set of clustered matches through separation. Let's expand this metaphor to understand the findings from our simple model... [4/8] pic.twitter.com/oulEYrrHOM— Benjamin Kerr (@evokerr) March 14, 2020
Consider this set of matches near a flame. To avoid an all-out blaze, would you focus on moving back green or red matches? Whether any given match ignites depends not only on its position, but also on how many other matches are lit, a factor altered more by majority retreat [5/8] pic.twitter.com/X4edadBqjr— Benjamin Kerr (@evokerr) March 14, 2020
Similarly, social distancing practiced by a majority fraction of a population can be a powerful way to mitigate the spread of disease. Of course, it would be best for all of us to embrace sensible measures to limit transmission (social distancing, hygienic practices, etc.). [6/8]— Benjamin Kerr (@evokerr) March 14, 2020
However, to expect the most vulnerable people (those most in need of support) to be the only ones to alter behavior is not only unfair, it is a severely suboptimal approach from a public health standpoint. Low-risk individuals also need to be part of these efforts. [7/8]— Benjamin Kerr (@evokerr) March 14, 2020
Social behavior w/ low *personal* health risks can have a high impact on *public* health. Proactive measures by low-risk individuals can carry profound & positive consequences. It is up to all of us, together, to #FlattenTheCurve & protect the most vulnerable among us. [8/8]— Benjamin Kerr (@evokerr) March 14, 2020
Coming back to 'flattening the curve', it is a term that I've heard used over and over again in recent days. According to NPR, "It's all part of an effort to do what epidemiologists call flattening the curve of the pandemic. The idea is to increase social distancing in order to slow the spread of the virus so that you don't get a huge spike in the number of people getting sick all at once. If that were to happen, there wouldn't be enough hospital beds or mechanical ventilators for everyone who needs them, and the U.S. hospital system would be overwhelmed. That's already happening in Italy."
The New York Times, in their Daily podcast, addressed social distancing. You can listen to that for free, here.
In conclusion, the world is being faced with a global health emergency on the scale of which has never been seen before in our lifetimes. Make no mistake: the coronavirus is a deadly virus that has already claimed thousands of lives, and it shows no signs of slowing down. We have nothing in place to combat this yet - no medicines, no vaccines, and no way of treating it. The only thing we can do is what works, and that's social distancing. While I feel sorry for businesses that are suffering the effects of this virus, especially small family-owned businesses, the truth is that we are all suffering. This disease has impacted our lives, our communities, and our work. It has - and will continue to - impact the economy. We're just getting started. Employers need to be flexible with work arrangements, and schools and universities have to make other arrangements. People have to stay home. Because, like it or not, social distancing is the only thing at the moment that is working.
Header image: A completely empty San Marco Square is seen on March 9, 2020 in Venice, Italy. Prime Minister Giuseppe Conte announced a national emergency due to the coronavirus outbreak and imposed quarantines on the Lombardy and Veneto regions, which contain roughly a quarter of the country's population. Italy has the highest number of cases and fatalities in Europe. The movements in and out are allowed only for work reasons or health reasons proven by a medical certificate.The justifications for the movements needs to be certified with a self-declaration by filling in forms provided by the police forces in charge of the checks. (Photo by Marco Di Lauro/Getty Images)