I am thinking out loud here. Since that's never a pretty sight, you might wish to avert your eyes. With that merest of advance warning, the school closure problem has gotten me to think more generally about social distancing. The term itself is a kind of oxymoron. "Social" emphasizes togetherness, intercourse between people, relations. "Distancing" is negation of the social. We have examples: canceling school, prohibiting mass gatherings, telecommuting, but the underlying idea is straightforward. With a contagious disease that passes from person to person (details still to be worked out, of course), we decrease transmission by minimizing person to person contacts, i.e., we distance people from each other -- social distancing. Decreasing transmission has benefits, even in the case where the total number of people infected is the same over the long run. If we flatten out the epidemic curve (the graph that shows how many new cases appear each day); and move its peak which is now lower to a later point, we have bought time and stretched out demand, easing the burden on health services. Those are the benefits.
There are also costs. Not only the costs related to lost school days, missed work and all the rest of the obvious consequences. But the loss of social relationships which are key to a community's resilience and ability to get through an event which affects everyone at once. We can see this if we take the objective of social distancing to its logical conclusion: what if we all hid away, each from everyone else. No medical care, no family member caring for a loved one, no worker picking up the slack of a sick colleague. No one at work, no one at school, no one in government offices. Each person hiding under the bed with a month's supply of water and tins of tunafish. Travel on air, sea and land shut down. Individuals traveling in cars couldn't get gas because that might put them in contact with others and supplies couldn't get anywhere either because our supply chains aren't set up to run in a completely automated way, with no human contact anywhere. Anyway, where would they go? And why?
Of course it's infeasible, but assuming everyone had prepped by laying in a personal supply of necessities, it would work. Disease transmission would stop within days. The pandemic would be over and many lives possibly saved. Of course not everyone would be better off. Many people would also die that would otherwise have survived had care been available. How would it net out? Let's say that on balance the same number of lives would be saved as lost. They wouldn't be the same lives, of course. Just the numbers would be the same. In one case, it would be those who had fallen sick and needed some help from others to survive that would be saved. In the other case it would be those who won't get sick and subsequently die regardless of what care was available who would be saved. Nor do we know it would even net out positively, given the sacrifices that would have to be made.
The point is obvious, once stated. The strategy of social distancing involves a risky choice of what kinds of social ties to break, how to break them and how to keep them broken for a length of time that is not certain. Some kinds of ties might be obvious. Mass rallies and gatherings, athletic events, concerts all would seem expendable (not if your livelihood depended on them, of course; everything is a trade-off). When we get to mass transit and schools, things get dicier. Let's take schools. The effect on students can be finessed most easily. They can make up the work in a variety of ways. But the loss of public childcare (which is one function that public school serves) is another matter. Parents send sick students to school and want well students to go there even if it means risking getting flu because it is an economic necessity. School's are a breeding ground and source of disease spread in a flu pandemic. They are kept open longer than necessary mainly because the economic consequences of closing them are so severe. The major place to look in managing the school closing problem is in sick and family leave policies. Instead we argue about triggers for school closings, ignoring the major impediment. This is a general feature of interfering with social relationships. It often has widespread unintended consequences.
There is something else about breaking social relationships that requires caution. In every pandemic people have simultaneously shunned their neighbors out of fear and helped their neighbors out of an innate sense of responsibility and empathy. Both are likely hard wired into human behavior because of their survival advantages. Both behaviors can be suppressed or amplified by public policy and planning. We could, for example, set up efficient ways to allow people to volunteer and place those who wish to do so in the most advantageous and useful places. Or we could make it difficult for them to do it by instituting blind quarantines and rigid public curfews.
There's still time to think some of these things through, and the investment will pay off handsomely I have no doubt. But I also have no doubt that in a crisis, we will also figure out all sorts of work arounds and clever solutions. Since this will be neither the last pandemic nor the worst we've ever seen (at least I hope so), we should be prepared to harvest our experience of what works and what doesn't.
Just another thing to add to the planning protocol: recording what we do.
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This is something I've been thinking about for the fall. A personal example - I work at home and homeschool two kids, so social distancing would be very easy for us (we could just stay home from all the "extra" stuff like field trips, sports practices, classes, etc.) but would cost a lot (we would get really sick of each other, we would miss our friends, we would not contribute to our group, we would not help other families with child care and transportation). The trade-off is hard to calculate, but it's a call I'm going to have to make this September, whether I like it or not. I expect that I will make decisions about each event on a case-by-case basis based on easily acquired "information," and I'm willing to bet there are a lot of other people who will be doing the same thing, barring reasonable guidance from a credible source.
Prohibiting mass gatherings would be a great temptation for tyrants. Making them unattractive would be a job for educating people to take flu seriously, though, and constitutionally more palatable.
It occurs to me that I've never seen a character in a TV show die from the flu. Maybe one should.
I'd be happy if we could just do away with the custom of shaking hands. Much prefer the "terrorist fist-bump".
This was the topic a series of meetings and discussions (including the name!) dating back to at least 2005, involvoing many parts of the health system including academia, IOM, ASTHO and public input. That doesn't mean the right answer was arrived at, but even getting this far was like running in molasses (this CDC policy was from 2/07, note the date):
http://www.flu.gov/plan/community/commitigation.html
Getting to the point where policy was recommended hit a lot of push-back. There are still people who would like to see it undone. Keep that in mind.
Dem: It depends on what "this" and "it" mean. The name is part of the problem because it covers a vast array of good and bad policies, which is what I was trying to get at. The question is't whether we should or shouldn't do things that now go under the name "social distancing." They will be -- and are being -- done. I was trying to point out that inherent in social distancing is the (intentional) alteration of social relations, something which should be considered explicitly, not just in terms of disease transmission. In terms of school closures, those social relations are mainly economic and need to be thought through from that point of view as much as from the point of view of disease transmission. If the latter demands it (and i think in many cases it will) then we need to direct our attention to the former (the economic issues in terms of sick and family leave policies).
OT but not by much. Reuters has an article this morning about the new flu. Animal studies show that it can infect deeper in the lungs than seasonal flu. Going to be a long fall and winter.
This pandemic is off the radar among the general population in North America but the medical community hasn't underestimated it. Nor should they.
revere, what I mean was that the consequences of social distancing were very much considered along with the disease transmission aspects, and it was the effects on social structure that were anticipated and discussed. And it was those effects that made it a difficult policy to endorse.
For that reason, ASTHO was recruited to hold 4 across the country 'listen to the public' meetings to discuss exactly that.
Simultaneously, I was at 2 separate non-Fed meetings in 2005 where the name 'social distancing' was discussed, but no one had a better suggestion.
Four years later, the fact that the issues are coming up, and are not resolved, is not a surprise. These are difficult real world topics with real repercussions. It is interesting that the issue of consequences of enacting school closure was anticipated, and that despite the difficulties, it was recommended anyway as policy. Makes one hope.
Dem: Ah. thanks. Didn't understand you. Yes, it remains problematic. I think using "social distancing" as a label for different kinds of interruption of social relationships is part of the problem. Not much truly new in this, I guess.
raven: Just read the Nature paper and if I get my energy up will comment on it tomorrow. It is a strange piece and perhaps less there than meets the eye.
Some social distancing policies have unintended consequences that defeat their purpose such as, high school students who go to the mall or the beach together because they have a day off from school. Or a few mothers who stay at home organizing a softball game for all the kids out of school to keep them occupied while most of their mothers work. In hard economic times, very few parents will take off work to supervise their children. I even heard of a case where many children were dropped off at libraries for the day until their parents got off work. Even when children stay at home, they often go over to each others houses when they donât have to be in school. During a recent school closure for flu, I encountered many mothers at the grocery store with their children in tow. (Grocery stores are a breeding ground and source of disease spreadâ¦..)
When I was school age in the 50s and 60s, most mothers stayed at home and a school closure could more reliably keep children somewhat socially isolated. Most high school students at that time did not drive which cut down tremendously on their mobility. Fewer high school students worked at a job outside school. In todayâs world these children are much more independent and school closures have lost many of their benefits.
I agree better family sick leave policies would be helpful. I donât know what would make some people take a pandemic more seriously. I do think that if there were a way children could continue their studies daily by computer and be held accountable for that progress while staying at home, it would be helpful. It would require that schools have a way to continue instruction online and that all students have access to the Internet. Again, it would require supervision.
I came across this item yesterday in Moscow news, which I found surprising. Do you think there is anything to it? I am one of those people who usually takes aspirin rather than Tylenol, especially for fever reduction.
Russian doctors say treating swine flu with aspirin causes coma
9 Jul, 12:58 PM
Scientists of the St. Petersburg Research Institute for Influenza are warning everyone against treating or trying to prevent swine flu with aspirin, the combination is likely to send you into a coma.
The St. Petersburg Research Institute for Influenza is currently testing a new vaccine against the A/H1N1 virus. During the tests, the medics came across the unusual aspirin findings, Life.ru website writes.
Experiments revealed that as acetylsalicylic acid makes contact with the swine flu virus, it dramatically increases the risk of coma.
âThere are statistics that show how patients with swine flu who take aspirin have an increased risk of developing so-called Reyeâs syndrome,â says Anna Saminina, head of the biotechnologies lab at the St. Petersburg Research Institute for Influenza.
âIn other words, the patient may fall into a coma and never wake up, as their brain and liver are gradually destroyed.â
While the mechanism of this effect is yet to be studied, the institute has issued a warning against take aspirin as treatment or a preventive measure for swine flu.
âUse any other fever medication, but not aspirin,â Saminina says.
http://mosnews.com/society/2009/07/09/swineflucoma/
I don't think that social distancing is such an either/or scenario as you have painted its costs/benefits. For one, with the kind of communications many people have social distancing may only be an elective physical distancing like the first commenter pointed out, but with real benefits to the people who can't stay at home since they will have to be in contact with that many fewer people thus reducing their chances of getting the flu and hopefully helping attenuate the contagion itself.
@Linda Many of us are perfectly happy to stay home from school and play video games or chat/message/text our friends. Jobs, I think, are more of an issue.
anon: Actually, I was trying to make the point that it's not either or but requires careful choices because when you interrupt social relationships you can have unintended consequences.
"How would it net out? Let's say that on balance the same number of lives would be saved as lost"
Your thinking aloud has offered no evidence to support this. How many people depending on medical service, medications or who get ill during the social distancing would die?. Hygiene would be a problem, public disease would spread as a result of trash not being picked up, contaminated water supplies as water treatment plants break down due to lack of maintenance. Power and fuel disruptions during winter or summer would lead to increased number of deaths from the cold or to a less extent heat. Also, how many people live from pay check to pay check and would be unable to stockpile food and drugs and would starve or die from untreated diseases.
Obviously, some middle ground would alleviate some of these problems, but by starting out with a false premise that net fatalities will be the same even with such extreme social distancing these problems might not be adequately addressed.
"Disease transmission would stop within days. The pandemic would be over and many lives possibly saved."
Again, zero evidence to support this. We do not even know where seasonal flu hides out before coming out to bite us each year or even all possible ways it can spread (in HK SARS was found to spread through the plumbing and via rats so people who were socially distanced were spreading the disease). Why are you so certain a pandemic would not just lurk in the environment and strike again when it has more hosts available. Perhaps the next wave would even be deadlier or more contagious as people let down their guard and the virus evolves to account for fewer available hosts brought on by social distancing and fewer hosts with partial immunity as they escaped infection in the pandemics milder phase.
Lets go back in history and look at the result of extreme social distancing. In Europe you had a densely populated agricultural society with many diseases from close animal contact on farms the population had developed partial immunity to, and you had low population density hunter gatherers in the Americas (agriculture was in it's early stages) separated by an ocean of water. When the Atlantic was crossed and social distancing between the 2 cultures was brought to an end, the natives were defenseless against a host of new diseases. Their isolation worked against them and much of the native population was reduced by non-violent means (bullets took their toll as well).
In todays global village, we have no such effective separation so diseases tend to have a global reach and populations all have a chance to develop community immunity. This may very well prevent the severity of the next pandemic. Isolation of communities, countries and regions to counter the spread of a new disease may very well be counter productive. This does not mean they should
seek out infection of course.
Certainly in a real pandemic where the outcome of catching a pandemic flu is significantly worse than season flu, social distancing must be considered. School closures, banning crowds, etc will all slow the disease even if it is unlikely to stop it from running it's course. The objective is limited though, it is simply to buy the health care system more time and reduce the overload, and not to eradicate the influenza virus which is simply not understood enough to do. So I agree on this point.
Those with children would need government protection to prevent loss of jobs so they can take care of their kids at home, and for single parents some government assistance may be required to make up for the loss of a pay check while they are at home.
pft: I think you missed the point. Even if it did net out positively, we'd never do it, was the point. So we are looking for the sweet spot between going all the way and doing nothing. What are the principles to get us there? That's what I was asking.
Back in 2005-6 when the pros and cons of social distancing was being thrashed out on Fluwiki wrt H5N1, the "benefit ratio" seemed to be dependent on the CFR. I don't think anything has changed.
If the CFR is bad enough (and what is the public's perception of bad enough?)then the risk to the lives of our kids will be a strong motivator to adopt widespread social distancing. And the ancillary impacts on the economy, breaking(temporarily) social relationships, effects on supply chains will all take a back seat to a primordial response from parents > protect the kids.
We discussed back then how to mitigate the impacts on supply chains etc., but here we are 4 years later thinking about a much more severe pandemic than is currently underway. There are solutions to these issues eg school closures, community volunteer care, supply chain continuation with PPE, but they are all balanced by the perception of how likely each of us is to die if we get infected, no?
From my discussions with my local community officialdom and just folks over the past few years, I think a severe CFR event will cause people to vote with their feet on social distancing. They will hunker down, but if unprepared to do so, it will be chaotic and ugly.
So really, we are still discussing the impact of a significant proportion of the population dying, versus the impact of strict social distancing in order to minimise those deaths and end the pandemic as quickly as possible.
I wonder if this has been modelled with the economic impacts of the two scenarios compared?
A school nurse (don't recall from where) recently posted her experiences in handling sick students when a flurry of cases hit the school last month. Her plans for the new school year based on that experience may work as a general plan for handling school outbreaks. What she proposes is to have all arriving students who feel unwell report to the auditorium, where she will use the forehead type thermometers with the help of aides to check temperatures. All those that are ill will remain in the auditorium in isolation to avoid infecting the rest of the students in the school until their parents can pick them up.
This would help keep schools open unless and until the severity of the flu became such in terms of numbers and seriousness of symptoms that parents and/or school districts would agree that it was in the best interests of all to close the schools.
Another plan (I proposed earlier to my DOE superintendent)is that informational pamphlets regarding the swine flu be given to all school children to take home at the start of the school year. These would include a list of those underlying conditions most at risk for serious complications from this flu. Parents would be advised that if they, their children or any close family member had any of those risk factors, they could opt to keep their child home during any flu outbreak without penalty, and that alternative home lessons would be provided.
A strictly and globally enforced social distancing (i.e. self supplied self quarantaine ) for as short a period as, say, 8 days should be able not only to delay and flatten the peak but to virtually 'stomp out' any flu pandmic ...
I can imagine that the total socio-economical cost of a complete 8-day 'global economical freeze' would be lower in the end than the total costs integrated over the complete course of even a moderate (not to speak of a severe 1918,H5N1 style) pandemic when letting run its full course .... not to speak of the millions of lives that would be saved with the '8-day-global-quarantaine-freeze' method ...
But as, at a large scale, money is always more important than lives, the quarantaine solution is of course not going to happen in the real world :-(
Revere, you made reference to the fact that Moms used to be home and so there might be a different outcome, but now they have to work. No doubt some do, but most I know choose not to be home, and it is this group that loads the kids up on Tylenol to get past the school nurse, knowing exactly what they're doing. This mindset is what will upend all the plans of epidemiologists and scientists in high places and needs to change before Revere's quite reasonable precautions and preparations will be taken seriously. Question: who will scare these people into believing they need to be responsible, and quickly?
Columbkille: For the record, I don't think I was the one who commented on Mom's staying at home. I recognize, from my own family, this is not the norm any longer and it isn't economically possible for many, perhaps most, families in the US. Epidemiologists and public health officials are not counting on this nor do we believe it will happen. That's why we need to look to policy, in this case, sick and family leave policies, that will make it easier or possible to do what needs to be done -- not send sick kids to school.
I think that with less stay at home parents, these measures of lockdowns and quaratines when a school is closed is going to be less effective. I think CDC will need to learn that there may be infection outbreaks in children where the source of the outbreak is non-school, or in adults where it is other than the employer. If transmission occured in a public setting (such as a friends house, grocery store, mall, movie theater, amusement park, arcade, bowling alley, etc), it is likely a risk that people will take and that some people may get sick from a non-family source, and not everyone will be tracked. If people don't social distance, that is the price society will pay for people who violate the CDC recommendations.