Background
I’ve written and spoken a lot about how we can optimize our internal immune system function to thwart a Covid-19 attack without causing friendly fire and damaging our own body. If you’re not familiar with my approach to doing this, be sure to download my free Covid-19 guide here. I’ve strayed away from discussing how to minimize external viral load exposure since there has been plenty of discussion around that topic. However, I continue to get lots of questions like “what exactly is a safe distance from people?” or “should I meet up with friends in a huge cabin?”
I will provide a common sense approach that I personally use when I assess the risk of being in any situation that involves direct exposure to other human beings in our Covid-19 environment. Much of this won’t be new to you, but it might give you a more practical framework that helps you make decisions to help you minimize viral exposure risk. I call it my “4-D Approach,” where you can picture 4 protective doors walling you off from the significant threat of infection. I’ve listed them below and we’ll discuss each in more detail
- Distance
- Duration
- Droplets
- Disinfectant
Distance
You might have read conflicting reports about what a safe distance is when being around others. I think it’s silly for us to use an absolute number because there are so many different variables involved. Let’s use a car tailgating analogy. If I were to ask you what is a safe driving distance to keep from the car in front of you, would you give me a specific distance like the length of 6 cars? A more appropriate answer would be “it depends.” A safe distance you keep from the car in front of you is influenced by factors such as:
- Your driving speed
- The condition of your brakes
- Weather and road conditions
This is the same lens you need to apply when thinking about your distance from someone else. You may want to increase your distance from the standard 6 ft recommendation if the following apply:
- The person is a loud talker, especially a talker who tends to spit a little. We all probably know someone who does this
- The person is a cougher or sneezer either from infection or even from allergies. A single sneeze can launch viral particles over 20 feet.
- The person is higher risk based on age and/or co-existing health conditions.
Duration
We’ll stick to our driving analogy here as we talk about distance. Now imagine that you are not just a tailgater, but someone who likes to ride someones bumper for several seconds. That would multiple your risk substantially. If you drive in freeway traffic, there are times you need to weave in and out of traffic and transiently tailgate someone for a very short time to get into another lane or onto an exit off ramp. If you happen to be in a circumstance where you are closer to someone than you’d like, you want to minimize that encounter and keep it to less than 15 minutes. The shorter the better.
I’ll give you an example. I was in a situation with a very pleasant neighbor I ran into during a walk. She wasn’t wearing a mask, she was speaking loudly but nicely, and she was too close for comfort. After exchanging a few pleasantries, rather than make her feel bad and tell her to step back, I told her I needed to get home for a meeting, which was partially true. She was “tailgating,” so I decided to shorten the duration to minimize my risk.
Droplets
Your mask is your seatbelt. It’s a safety restraint system that limits the number of droplets being expelled into the air. Unlike a seatbelt though which is meant to protect you, it’s mainly protecting the lives of others. I completely agree with public health recommendations to wear a mask any time we are out in public, unless you are in outdoor, open, uncrowded spaces where people don’t linger in each other’s company. I don’t fault people for wearing masks outdoors. I’d rather have people err on the side of safer than reckless. Coming back to my neighbor, she was unmasked (no seatbelt), tailgating (close distance), and was potentially going to violate the duration limit if I let her speak freely at will.
Disinfect
People are slacking off on the 20 second hand washing rule. This has to happen, especially as viral loads go up. Anytime you leave the house and return, wash your hands for 20 seconds. Even while you’re in the house it doesn’t hurt to do this a few times a day and be sure to keep sanitizer handy whenever you go out.
Now based on available information to date, I feel comfortable not going through a stringent disinfecting protocol for takeout food, mail, and packages, but I would completely understand if individuals continue to do this. Everyone has their own level of risk tolerance, so if it makes you less anxious, there’s not much downside to you sticking to your protocols for now.
One thing I did notice is that I have some patients who are not buying any produce due to fears of Covid-19 being all over its surfaces and possibly causing an infection. It is extremely unlikely that you will get enough of a viral dosage of Covid-19 from eating produce. Our stomach acid is a powerful antimicrobial agent and now with so much worldwide experience we have not seen this as a likely mode of transmission.
Washing produce is a good practice regardless of Covid-19. Avoiding fresh fruits and vegetables altogether can weaken your immune defenses and worsen underlying health conditions that raise your risk of a more severe Covid-19 infection. If you absolutely cannot get over this fear, at the very least consider buying frozen produce which still contains good doses of nutrients. Multivitamins are not an adequate replacement for fruits, vegetables, and other nutrient-dense foods.
Common Social Situations
CASE #1- AN INDOOR GATHERING
I had an elderly Indian patient of mine ask me advice about throwing a sweet 16 party for his granddaughter. He was experiencing quarantine fatigue and didn’t want his granddaughter to miss out on a grand celebration. He told me they were going to order colorful masks for guests, provide gloves, and follow distance precautions.
I told him I would not recommend throwing the party for the following reasons:
- Masks may lower risk, but don’t eliminate it.
- People will not be able to adhere to distancing rules. It’s unnatural to stand 6 ft apart and talk to someone, especially with background ambient noise from other guests. My patient is hard of hearing and likely so are many of his friends, which means people will be talking loudly. Loud talking expels more virus which travels longer distances. I have never been to a party, especially an Indian party where people aren’t talking loudly!
Using my car analogy, an indoor party in a giant house with guests wearing masks is a bunch of reckless drivers in close proximity wearing seat belts. The masks partially reduce risk, but the other D factors (distance and duration) make this a risky endeavor. For this party, there would have been a mix of young teenagers and elderly guests.
Older individuals and/or those with chronic health conditions are more fragile vehicles, while young teens and children are more like bulky trucks and SUVs who might be asymptomatic carriers colliding into these smaller vehicles.
I picture a bunch of bumper cars at an amusement park. I told him if he wants a gathering, keep the guest list small, move it outdoors, have everyone wear masks, and distinctly place chairs and mark areas 6 feet apart. I could tell he didn’t like my answer.
I’m not trying to be a party pooper, but when you host a party, you are taking responsibility for the health of your guests. You need to provide a safe environment for all of them. By the way, if you threw the party and sent an e-mail 2 weeks later to see if everyone was healthy, would you pat yourself on the back and say “I did great!” No, because there is still a chance that virus might have gotten spread by an asymptomatic carrier, like one of the teens at the party.
In many of the outbreaks, individuals will likely never know the person who is harmed or may die as a result of someone’s careless actions.
Sounds harsh, but it’s reality. The sad thing is that many of us are taking safety measures every day by not hosting parties and by wearing masks and following the 4Ds, but we will never know the lives we might have potentially saved by doing this. If we did, we’d not engage in reckless behaviors and we wouldn’t succumb to quarantine fatigue, thinking all these measures are daily annoyances.
CASE #2- THE BIG CABIN/HOUSE GATHERING
Another concept I absolutely cannot understand is when people are telling me they are renting a gigantic house or cabin and having multiple people or families gather but they feel safe because the house is like 7,000+ square feet with multiple bedrooms. I don’t care how big this house is or how many rooms there are. Adults will typically congregate in common areas like the kitchen and main family room. Kids will disappear into bedrooms and dens without you having any clue because you’re too busy pouring wine into a friend’s glass and dipping pita chips into hummus talking about when the 2nd wave is coming or when a vaccine will be out.
People are so deprived of social contact that there is NO WAY they will be able to maintain a minimum of 6 feet distance over a period of days, especially once they get some alcohol into their system and their inhibitions and good judgment are further compromised.
So in this situation using my analogy, we have a group of drunk drivers tailgating each other for extended periods of time and I doubt that most of them will be wearing their masks (seatbelts), and this is happening during a time when we are seeing an absolute spike in viral activity. Once again, this group may be spreading virus (and harm) without knowing it, and because this particular trip appeared to go without a hitch, they will feel bold and courageous to keep being reckless with future activities.
CASE #3- OUTDOOR DINING
I’m also a bit dumbfounded how even in my strict county of Santa Clara, restaurants are open for outdoor dining without the appropriate measures. Basically tables are placed 6 feet apart, but individuals are sitting closely together; eating, talking and laughing, and it’s clear that these tables are not just limited to household members. I know they are outside, but friends, business colleagues, etc. are sitting well within 6 feet for an extended duration, spraying droplets on each other. Yes, being outdoors is much better than dining indoors, but I think the level of risk is still unacceptable given distance (<6 feet), duration (over an hour typically), and lack of droplet precautions (no mask in most cases).
Summary
I’m not forbidding all forms of social contact. I know I sabotaged a large, festive sweet 16 party and turned it into a smaller outdoor gathering, which is still modified social contact. My family is going to gather with a few other families for a few days in the mountains, but we have all agreed to stay in separate cabins and share a few meals outdoors in open space. I would much rather share a huge house with these friends, but I refuse to put my family and other people I’ll never know at needless risk just so I can maximize my own enjoyment. I’ve got enough years ahead of me where I can enjoy plenty of shared vacation home experiences.
Another factor you need to take into consideration are upcoming events where you are planning to visit or be visited by elderly and/or vulnerable family members or friends. This will be especially important during the summer and as the holiday season approaches. If such an event will take place, you (and others) should limit any high risk gatherings or interactions at least 2 weeks prior to the planned interaction with the vulnerable individual(s). Consider testing before the visit as well, and pay attention to public health guidelines or consult with your doctor for guidance.
This is an unprecedented time for most of us, but it will pass. I hate having to do a risk analysis every time we are invited to or planning some sort of social or family gathering, but this is the new world we live in right now. In each of the 3 cases I discussed, there is a good chance that if you ignored my advice, thinks would turn out just fine. No one inside or outside of your circle gets harmed or dies as a result of your actions. I can also confidently tell you that I can drink 3 glasses of wine right now, get in my car and drive to San Francisco at a speed of 90 mph, with a very low chance that I will kill myself or others on the road. However there is a small, but SIGNIFICANT chance I could injure or kill myself or others which is why I would never do this. Other alternatives exist, like me staying home and enjoying my wine or driving sober to San Francisco at the speed limit so I can enjoy the city while minimizing my risk.
I view our current COVID-19 environment the same way. Once we have an accurate test that tells us precisely if we have protective antibodies against COVID-19, we can loosen the reins a bit and modify our practices. Once we have a vaccine and have achieved herd immunity, we can loosen our reins a bit more. In the mean time I hope the 4D approach will give you a framework to simplify this process a bit and still allow you to enjoy a modified version of the usual social gatherings. I actually prefer socializing in smaller groups and being outdoors, so although there are things I miss, overall my social bucket of needs is getting filled. I’m also finding more of my close friends available for walks, hikes, phone calls, and Zoom sessions since they are spending less hours commuting and traveling on business.
Please don’t be a victim of quarantine fatigue and put yourself and others at risk by rebelling against public health guidelines. I’m finding a curious and careless sense of bravado emerging in even highly educated individuals (including some physicians) who are saying “enough of this…I’m going to live my life and do whatever the hell I want!” I know we like to blame our government for everything, but when you read about countries that have extremely low risks of infection, keep in mind that most of their citizens were willing to play by the rules and make the necessary sacrifices for the sake of the greater good. Until we truly get into a safer space, we need to do the same.
