The Inescapable Logic of Social and Physical Distancing and How to Live With it

Here in Vermont, we are in our third week under Governor Scott’s March 24th order:  “Stay Home. Stay Safe.” And it looks as though we will soon be approaching peak demand for hospital beds. So, despite the stress and anxiety we are all feeling, it is vitally important that we rededicate ourselves to maintaining the greatest possible social and physical distancing that we can manage. 

This e-Newsletter Special COVID-19 post will review the public health rationale for social and physical distancing and try to clarify how you might navigate “Stay Home. Stay Safe” to address your own personal physical and mental health needs, while protecting those of other members of your household. 

This is the third in a series of posts involving the interrelationship and tension between public health and personal health. The prior two posts are:  The Scientific Facts about Sanitizing Surfaces: Package Deliveries, Groceries, Mail, etc. and The Whole Truth About Masks and COVID-19.

Throughout this post, we will be quoting verbatim from sources with our added bolding to help readers focus on key points and use of [brackets] when we edit content for clarity.

I. Protecting Public Health
(Social and Physical Distancing)
ALERT: Even if you don’t read another word of this post, please watch this brief video from UVM Medical Health Network. In a minute and a half, it explains clearly and exactly why staying at home is the key public health strategy for beating COVID-19 and saving the lives of the most vulnerable Vermonters. 

The Goal
The principal public health goal of social and physical distancing is to slow down the spread of COVID-19 infection in order to flatten the hospital-demand curve so everyone who becomes sick or injured for any reason during the COVID-19 emergency can receive the medical care they need.

The Means to Attain this Goal

Time. That’s what staying home during the corona virus outbreak buys. And that extra time will save lives. 
Why? Because in Vermont and across the nation, a spike in the number of COVID-19 cases requiring medical attention threatens to overwhelm hospitals. There won’t be enough care for the critically sick. 
When each of us stays home, we will slow down the rate of infection. That, in turn, will slow down the number of high-risk people getting sick at the same time. “That means we are much more likely to save their life,” said Tim Lahey, MD, an infectious disease expert at the University of Vermont Medical Center in Burlington.

Flatten the Curve
If you’ve seen #FlattenTheCurve on social posts, that’s what it means. Stretching out the rate of infection over time so that hospitals can keep up, providing respirators and other critical resources that are a matter of life and death for people at high risk; older members of our community, people with compromised immune systems or other health conditions that make them more susceptible to infections.
Graphic showing how staying home flattens the curve 

Why Slowing the Contagion is Key
The virus is highly contagious. Nearly everyone will get COVID-19 at some point, Dr. Lahey said. So it’s unlikely that anything will completely stop it, which is why slowing it down is so critical.
  Graphic showing how social distancing slows the spread of infection

Our Call-to-Action as Community Members
The COVID-19 outbreak represents the worst public-health crisis the world has seen in a century, presenting us all with a once-in-a-lifetime call to action. A call that we all have a responsibility to answer.
“You need to save the lives of vulnerable people in your community by staying home,” said Dr. Lahey.
Staying home, frequently cleaning your hands with soap and water or sanitizer, disinfecting frequently touched surfaces and other good hygiene measures are all critical to help slow down the spread of COVID-19.

If you must go out, to the grocery store for example, make that trip as short and efficient as possible. 

Practice social distancing at all times. If the store has disinfecting wipes at the door or hand sanitizer, use them on the way in and on the way out.

And if you feel sick, but your symptoms are mild to moderate and can be treated at home, stay home. Remember that 80 percent of people infected with COVID-19 won’t need medical attention. But it’s critical that you isolate to avoid infecting others. 

When to be in contact with your personal health-care provider
Even though your symptoms may be mild and you are being cared for or caring for yourself at home, it is probably advisable to alert your PCP to your condition, by phone or, if available, on the PCP’s web portal.

Quarantine and Monitoring
As a public health measure, strict quarantine and monitoring may be suggested or required for people who have probably been exposed, including by others in their household, and others you’ve had contact with during the past 2 weeks who later tested positive; and it is now required for travelers from out-of-state.

Monitoring is for people who do not have symptoms and who have traveled to affected areas. It means checking your temperature daily, watching for symptoms, and for some people, staying home.

In the third section of this post, we will discuss what happens if your symptoms worsen. However, let us now turn to the role of social and physical distancing from the point of view of protecting our personal health and that of others in our household at this stage of the pandemic in our area.

II. Protecting Personal Health
(How to Live with Social and Physical Distancing)

Your Goal 
To not become infected, particularly if you are in a higher-risk category
OR at least to DELAY infection until the curve has flattened enough to allow area hospitals to provide the medical care you may need, again particularly if you are in a higher-risk category 

The Means to Attain your  Goal
If neither you nor anyone in your household has experienced any symptoms, the very basic Vermont Department of Health guidelines (as of 4/8/20) are as follows: 
There is currently no vaccine to prevent COVID-19 infection. Person-to-person spread of the virus is thought to occur mainly via respiratory droplets produced when an infected person coughs, sneezes or talks. People who are infected often have symptoms of the illness. People without symptoms may be able to spread the virus. Currently, there is no evidence to show that COVID-19 is spread through food, mail or paper products. It may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes, but this is not thought to be the main way the virus spreads.
Take these everyday (and by now probably all too familiar) preventive actions to help stop the spread of [COVID-19 to others]:
    • Stay at least 6 feet away from others.
    • Stay home as much as possible.
    • Avoid close contact with people who are sick.
    • Avoid touching your eyes, nose, and mouth with unwashed hands.
    • If you must go out, practice social distancing
    • Cover your coughs and sneezes with your sleeve or a tissue, then throw the tissue in the trash and wash your hands.
    • Clean and disinfect frequently touched objects and surfaces using a regular household cleaning spray or wipe.
    • Wash your hands often with soap and water for at least 20 seconds. If soap and water are not available, use an alcohol-based hand sanitizer. Always wash your hands if your hands are visibly dirty.

In addition, the Vermont Department of Health provides this advice about mental and emotional health while practicing social and physical distancing. 
During this time of uncertainty, many Vermonters are feeling understandably angry, worried, and scared. Staying away from friends and family can make the feeling of isolation worse. We encourage all Vermonters to keep connections with family, friends, and your community in new ways. Use technology to communicate, enjoy the outdoors, take time to learn a new skill, follow up on long-overdue projects, or volunteer to support those who may be in need.

It is important to get outside for fresh air and exercise. Spend time outdoors as a family or consider individual outdoor activities like biking or hiking, as it's easier to keep a good distance from each other. Exercise and taking in Vermont’s natural beauty is important for our mind and bodies. We can safely continue to enjoy the outdoors with these measures:
    • Stay close to home. Find areas close you can walk or bike to. If you must drive, please limit the distance from home to ten miles, and only drive with members of your household.
    • Practice social distancing while outside. You lower your risk when you stay at least 6 ft apart from others. This includes having your dog on a leash and close to you.
    • Be cautious and choosing low-risk activities to avoid injury. This will help lower the burden on the our hospitals and health care system.
    • Respect signs for closed areas, trails and land. Check to see if your trail is currently open before you visit.
This is a big transition in how we all live our daily lives – we’re all working together to adjust, change the way we express kindness and affection to others. Knowing this – all being in this together – goes into all of the difficult decisions the State is making.

And, very recently, the Vermont Department of Health has changed its recommendation about wearing masks when going out in public; it now reads as follows:
Vermonters should wear cloth facial coverings when they leave their homes for any essential purposes, like grocery shopping or to the pharmacy, or outdoors if other people are nearby. The advice to wear cloth masks is based on new data about how COVID-19 can spread before a person has any symptoms. Because people may have COVID-19 but no symptoms, wearing a face mask may help keep people from spreading the virus.

Face coverings are not a substitute for physical distancing (or “social distancing”) and other prevention measures. 

The most effective way to slow the spread is to continue to follow the governor’s Stay Home, Stay Safe Order, and social distancing, as well as regularly washing hands and not touching your face.

Medical-grade mask supplies are needed for our health care workers and first responders. Please use cloth or other recommended facial coverings for your yourself and loved ones.
We would add to all the above Vermont Health Department guidelines for people who are socially and physically distancing by staying home:

Self-observation: Maintain a watchful eye on yourself and other members of your household for possible symptoms, such as a fever, cough or difficulty breathing; if you detect any of these, contact your personal health care provider immediately. (See section III, following.)

III. What To Do If and When You Experience More Serious 
COVID-19 Symptoms
(when personal and public health considerations may conflict)

No matter how carefully we have been to protect ourselves and/or our loved ones with prevention measures like physical/social distancing and hygiene, there is still a chance that we will become seriously ill with the worst symptoms of COVID-19 infection.

This is when, for us as individuals, personal health considerations will be paramount. However, because we or loved ones are now confirmed carriers of COVID-19, it is also even more important than previously that we also strictly observe public health measures. As a result, and as you will read below, there will be situations in which the interrelationship of personal and public health will lead to tensions between the two.

When to seek medical care
According to the Vermont Department of Health, you should seek medical care from a doctor [or other appropriate health professional] immediately: 
 “...If you have difficulty breathing, chest pain, confusion, or changes in color on your lips, gums, face, around the eyes, or nails, seek medical care immediately. When you call for medical care, tell the provider or 911 that you have COVID-19 and are isolating at home.” (April 1, 2020)

Call your doctor [or the nearest clinic or urgent care facility] and ask to be seen for an evaluation. Do not go to the doctor's office unless instructed to do so. Anyone who does not have a health care provider can call 2-1-1 to be connected to a clinic in their area.


What about Testing?
Although the amount of testing being done in Vermont is slowly increasing there are still not enough testing kits or processing capacity for everyone to be tested. (As of 4/8/20, just 7,750 tests have been performed, meaning less 1.5% of Vermont’s population has been tested.) 

Clearly, the state must and is giving priority to those in most need of testing, which are decisions that are being made by medical professionals. At this time, it appears that the two main criteria for testing are: likely exposure to a known carrier AND the seriousness of symptoms
According to the Vermont Department of Health website (as of 4/7/20):
Your health care provider will arrange for testing if they determine that a test is needed. There are several testing sites and drive-through locations across the state with more being added. These sites only collect samples from people who have been referred by a health-care provider. The state will ensure that anyone who meets the medical requirements for testing for COVID-19 can do so at no cost.

What to do while waiting for test results
If you [are] tested for the 2019 novel coronavirus (COVID-19), it may take a few days for the results to come back. Your medical provider will notify you of your test result. The Health Department may reach out first with recommendations or to ask questions about contacts [i.e., people who you may have, inadvertently, infected or vice versa.]
Things to do while you wait for test results are pretty much the same list of “everyday preventive actions” listed in section II, above, with the following significant changes:
  • Stay at home. Do not go to school, work or any other public place.
  • If you need to see a health care provider, call them first and tell them that you were tested for COVID-19 and are waiting for results
  • Separate yourself from people and pets in your home, as much as possible.
  • Wear a mask if you cannot avoid close contact with other people and pets
  • Routinely clean and disinfect frequently touched surfaces and objects.

What to do when the test results come in:
Here’s where things begin to get complicated and you really need to read and follow the instructions in: Waiting for test results from the Novel 2019 Coronavirus?” fact sheet, Vermont Department of Health, (4/6/20):

What to do if you (or someone in your household) is confirmed by testing to be infected  with COVID-19

Complete isolation (and care) at home is strongly recommended for those with mild symptoms in order to protect other members of their household or others who may need to come into the home. 

According to the Vermont Department of Health in their “What to do if you are diagnosed with COVID-19” fact sheet, 4/1/20), this means the following:

Isolate at home:
 • Don’t leave home, except to get medical care. Call ahead before visiting a health care provider or emergency department
• Most people with mild illness can recover at home. While there is no specific treatment for COVID-19, you should get plenty of rest, drink plenty of fluids, and take fever-reducing medication if needed. 
• As much as possible, stay in a specific room in your home and use a separate bathroom. Stay at least six feet away from others in your home at all times. Don’t share household items. 
• Have someone else care for your pets. Although no animals have been reported to get sick with COVID-19, people with the virus should limit contact with animals until more information is known. If you do care for your pet, wash your hands before and after.
 • Stay connected with others – use technology to communicate with friends and family. 

Daily cleaning and washing: 
Clean and disinfect surfaces in your separate room and bathroom. Have someone else clean the other areas of your home [that you may have touched recently]
• Thoroughly wash household items, like utensils, after using
Wash your hands often with soap and water for at least 20 seconds. Use alcohol-based hand sanitizer if soap and water aren’t available. 

And, for reasons of public health, follow the directions in this same fact sheet from the Vermont Department of Health regarding notifying people who have been in close contact with you while you were infectious.


IV. The Public Health CHALLENGES to Treatment
If in reading some of the above guidance from the Vermont Department of Health, it may seem like a kind of CATCH-22 situation, let’s at least understand why this may be the case by looking at the dilemma faced by hospitals and public health officials:

1. Limited Hospital Capacity: only so many beds available for patients
2. Shortages of personal protective equipment (PPE): Face shields, gloves, goggles and glasses, gowns, head covers, masks, respirators, and shoe covers are all needed to protect health workers from becoming infected through contact with COVID-19 patients.
3. Limited numbers of ventilators: These are needed for people who are having difficulty breathing, but there is a nationwide shortage of these expensive items.
4. Due to 1-3 above, hospitals can only admit those in greatest need of hospital care
5. Thus, the Vermont Department of Health has, in effect, established a two-step “triage” process to determine who can be admitted to a hospital at this time
  • a person’s PCP or other health professional must screen the person to decide if testing is warranted and, if so, they must prescribe it; 
  • then, if the test is positive, the PCP or other health professional must also determine that the patient’s symptoms are serious enough to require hospitalization. Only then can hospital admission be prescribed.
6. However, and here’s the “catch,” due to the continuing shortage of test kits and the limited capacity to process the tests in a timely way, in Vermont at this time almost the only people being tested are those with serious symptoms and then only with a prescription from a PCP or other health professional. (Note: in certain rural areas of Vermont like the Northeast Kingdom, there are so few health professionals available that a person would have to travel a considerable distance even to be evaluated to qualify for testing.
7. Therefore, in too many cases, by the time positive test results are confirmed, the virus is wreaking havoc in their lungs and these people arrive at the hospital even sicker than when they initiated the call for help from a health professional.
8Indeed, many people arrive in critical condition and are immediately sent to intensive care, which requires greater medical attention, more personnel using hard-to-get disposable PPEs, and often, limited and expensive ventilators.
9. As a result, many more people are dying than would have if they’d been admitted when their symptoms were less severe. 
The above scenario, repeated over and over in American hospitals over the past few weeks, has also created a public communications nightmare for state health departments when media outlets (like VTDigger) draw misleading inferences from Department of Health updates on daily and overall case and death rates. 

For example, the U.S. (and Vermont) death rate statistic (# died/confirmed cases) is MUCH higher than in Germany and other countries where mass testing is being carried out; this is for two reasons, one real and the other a statistical distortion
  1. Real: The # died (numerator) in the U.S. and Vermont statistics are larger because, as described above, patients arrive at hospitals far sicker (and closer to the tipping point toward death)
  2. Statistical distortion: the confirmed cases (denominator) in the U.S. (and Vermont) statistics are much smaller because, unlike countries where most people are tested, our states do not test and therefore do not  include people with mild cases. 
So, not only are the U.S (and Vermont) death rates actually higher (because so many people arrive at the hospital too late to be saved), but they appear to be much higher because of the statistical distortion arising from a paucity of testing. 

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