The United States is charging ahead with reopening. All 50 states are now moving to reopen their economies, even though only three meet basic criteria to do so safely. Coronavirus cases are rising in some states, yet public officials there are still choosing to open bars, restaurants, and more.
Meanwhile, Canada is trying out a much more modest experiment in easing social distancing. Based on early data, it seems to be working out.
Our northern neighbor has been doing far better than the US at keeping case numbers down, partly because its political system works. Its per capita Covid-19 death rate is roughly half that of America’s.
So, lately, some Canadian provinces have begun allowing people to form “double bubbles.” That means two households can now make a pact to hang out with — and even hug — each other, so long as they agree to stay distanced from everyone else. The hope is that doubling the family bubble will reduce isolation and its toll on mental health, while also helping with things like child care. This is meant to be an intermediate step before opening up further.
Canada borrowed the strategy from New Zealand, which used it to great effect before virtually eliminating the coronavirus. A few European countries, such as Germany, have also tried it before progressing to more drastic reopening measures.
In Canada, New Brunswick became the first province to permit its population to double-bubble on April 24. Newfoundland and Labrador followed on April 30. And Nova Scotia gave the go-ahead on May 15.
These provinces could afford to ease social distancing restrictions because they have very low case numbers. (Throughout all of May, none of them surged above 15 new cases per day.) It’s still deemed too risky to do this right now in Quebec or Ontario, where community transmission is much higher.
Now that more than two weeks have passed since some provinces allowed people to double-bubble, we can expect that any resultant rise in daily new cases would be showing up in the data. But the data show no such rise.
“In the last few weeks, there has not been a rise in cases — in fact the opposite is true,” Isaac Bogoch, an infectious disease specialist at Toronto General Hospital, told me. “This is a very smart and creative approach to the early phases of lifting the public health restrictions we’re living under.”
Some American experts, meanwhile, sounded a note of frustration that the US is adopting a more aggressive approach in its rush to return to normal. There are many gradations in between total shutdown and wholesale reopening, and although the US is adopting a phased approach to reopening, it seems to be leapfrogging over some of the more modest gradations — like the double bubble. Rather than telling people they can link up with one other household, some states are telling them they can go to bars, where they’ll come into contact with far more people.
That raises the question: Would it be wise to try double-bubbling even before opening up a bunch of businesses?
“Yes, I think this is something we need to be considering,” said Julia Marcus, an infectious disease epidemiologist at Harvard. “To me it seems like there’s a much higher risk when we’re considering something like opening bars, compared with two families carefully agreeing to have playdates between their kids.”
She added that what we particularly want to avoid is the occurrence of “super-spreader” events, where one person can infect many others at once. “That’s less likely to happen in the scenario of two families who’ve agreed to be in a bubble together. Even if one of them is exposed and the infection is passed between those two families, the overall risk to the community is lower than in a situation where you have 300 people in a crowded bar,” Marcus said.
“Plus,” she added, “if we can give people some choices for human contact with relatively low risk, they may not feel the need to go to a bar.”
The when, where, and how of double-bubbling
Canada’s embrace of double bubbles seems to have inspired some individuals in the US to adopt the approach, too, even in the absence of official US recommendations to that effect. But just because it makes for reasonable policy in New Brunswick or New Zealand does not mean it’s advisable everywhere else.
First, the double-bubble approach shouldn’t be tried in a city where community transmission is high and new cases are rising. For example, the experts I spoke to said this wouldn’t have been appropriate in New York City at the peak of its outbreak, and it’s probably still too risky there. But they said it’s something that should be done in areas that are ready.
“Assuming that a region is doing well in terms of new cases and the amount of community spread, this seems to me like a perfect example of how harm reduction can be applied to social distancing,” Marcus said. She argues that social contact is a basic human need and people are going to engage in it whether experts like it or not, so giving them a way to do it that’s as low-risk as possible is better than insisting on total abstinence from socializing.
But how low do a region’s numbers have to get before it’s safe enough to double-bubble?
“There’s no magic number. It’s going to be a value judgment, an opinion,” Bogoch said. “I know it’s not nice to talk about, but we have to make a value judgment on what’s an ‘acceptable’ number of cases and deaths.” It falls to government officials, under the guidance of public health specialists, to make these determinations.
Carolyn Cannuscio, a social epidemiologist at the University of Pennsylvania, warned me in April that attempts to form a “closed circle” of people who can safely socialize are not as safe as they might seem. Each household will have some baseline risk of exposure from going to get necessary items like groceries. And even if both households agree to the same stringent set of rules (for example, always wearing masks when outside the home), not everyone will stick to them with the same fidelity. People sometimes cheat on their social contracts or simply forget to communicate small lapses, especially to people who live outside their household.
This becomes riskier when you’re in a place with higher rates of community transmission. So, even now, Cannuscio said she’d avoid double-bubbling if she were in such a place.
But, she added, “In areas of low transmission, I would be willing to consider this. However, the person I most want to see is my mother, so I personally would prioritize her safety over all other considerations. For people with elderly or infirm family members they want to visit, they should limit other social contacts and not make their vulnerable family members susceptible to popped bubbles!”
In other words, it’s not necessarily a bad idea to double-bubble with a senior or an immunocompromised friend, but if you choose to do that, you need to be extra careful about maintaining social distance from everybody else.
“We have a reluctance in this country to embrace harm reduction”
If it’s prudent to try double-bubbling even before opening up various businesses, why haven’t US authorities promoted it? Why has the country skipped over that phase?
One obvious answer is the economy. The fact that some 40 million Americans are unemployed is certainly fueling the push to reopen as many businesses as possible, as fast as possible. People need incomes, and some think that economic collapse must be averted even if that means the death toll rises.
But Marcus said there’s another reason why US authorities jumped straight from total lockdown to relatively dramatic reopening measures (like allowing barbershops and bars to operate again) without considering the options in between.
“We have a reluctance in this country to embrace harm reduction,” Marcus said. Telling Americans in certain areas that they can see one other household would require trusting that giving them an inch won’t mean they take a mile. “Historically, one of the concerns about harm reduction that always comes up is this fear that if we give people any ideas about risky behavior, it will promote more risk-taking.”
In a sense, the US’s phased reopening could be seen as a form of harm reduction; it’s certainly safer than opening everything up immediately, without any phases at all. But the point is that to go from telling everybody to shelter-in-place to reopening certain businesses is still a big leap — and the US has failed to give individuals choices in between.
While Canada tends to look relatively favorably on harm reduction, Marcus said she sees a lot of the opposite approach in the US. She cited resistance to sex education and to the HPV vaccine (for fear that they will lead teens to have sex earlier) and opposition to syringe service programs (for fear that they will promote drug use).
“I think it comes down to having a more puritanical outlook on human behavior,” Marcus said. “The concerns often come from a place of moral judgment about what constitutes responsible behavior — that’s why we see the concerns come up most often in a context of sex and drugs.”
Study after study has shown that these concerns are misguided: Harm reduction tends to improve health outcomes, while more moralizing or black-and-white approaches (like abstinence-only education) tend to backfire.
This is as likely to apply to pandemic-era socializing as to anything else.
“If we don’t provide harm reduction guidance that acknowledges the risks people are already taking and in some cases need to take, we are missing an opportunity to mitigate risk,” Marcus said. “Instead, people might choose to see lots of different people one after another, with more potential to expose themselves or others.”
Unfortunately, in the US, many of us are already seeing examples of the latter behavior among our friends, families, and neighbors who want to socialize.