Updated: May 23, 2020
A better way to take care of one another as we start opening up society.
Link to article in Medium
Evelin Dacker MD
The coronavirus called SARS-CoV-2, or sometimes just “novel coronavirus,” is a new strain of a previously known class of viruses. When someone gets sick from this virus, it is called COVID-19 (CoronaVirus Infectious Disease, which was first identified in 2019). There is much that we have yet to learn about this virus. We don’t yet have good answers to help guide us and make us feel secure as we navigate forward with this new reality. Confusion, fear, grief, loneliness, loss of freedom and an unstable economy are struggles we are all facing.
What will be our “new normal”?
There are those who are taking physical distancing very seriously, and those who feel anger and frustration at being told what to do by our Government. Our current political climate is fragmenting us further. Most of us are concerned. We are impacted by the economic damages brought on by the closing of the economy, isolation from friends and family, and fear of sickness and death.
Some people are responding to this time with hope that a better world can be created. They see how the natural world is positively responding to decreased human impact. Others feel anger and resentment towards the authorities and those they feel are impinging on their rights. Many feel grief that the world we have known is changing in ways that we cannot comprehend or have any control over.
These stories and feelings can either tear us apart or bring us together. It will be our choice to make: Will our new normal be one based on scarcity and fear or on an abundance of hope and love? It is my deep hope that we can agree that human connection with others and with our planet is key to creating this “new normal.” We need to find that point where the freedom of the individual is balanced with care for others. It is here, I believe, that we can create a new world where we can all be seen and cared for equally, regardless of privilege.
To be honest about our current situation, it looks grim. Social distancing, isolation, and widespread testing are the best models we have to reduce harm. Yet humans are social beings. Loneliness shortens a person's life by 15 years and has the same morbidity as smoking and obesity. As our states and counties slowly lift restrictions, without the accuracy and wide availability of screening and antibody tests, people are bound to just freely enter back into society without thinking about those who may be vulnerable and harmed.
We cannot consistently and thoroughly maintain the level of social distancing we are asked to right now for the next several years, until herd immunity is achieved. We need to be able to lean back in towards each other with a consciousness that shows care for one another while reducing the risk of viral transmission. Otherwise the most vulnerable — economically, physically, mentally, and spiritually — will continue to suffer. This is just unacceptable.
I wish that I had the perfect answer to this, but I do have an idea that we can use as restrictions are lifted and we begin to decrease social distance while continuing to care for those at risk. Until accurate testing is available, I believe that self-awareness and communication is our third best tool. COVID CARE is a model in which we can each understand our own and our communities’ needs and risks and clearly communicate with others. By being honest and respecting others we can co-create a healthier expansiveness.
Covid CARE calls in four specific elements to consider and discuss with others as you start broadening your social circles:
Container, Agreements, Risk Tolerance and Etiquette.
Some people value sovereignty and autonomy. Others value other people’s needs and are able to sacrifice their own. Self-awareness is the first fundamental step in communication. We need to be honest with ourselves about our needs, desires and actions, then take responsibility for how those decisions affect others. This can be done intentionally and honestly, with clear communication.
I have seen the powerful changes that communication, disclosure, and self-awareness have made in people’s lives. We can learn how to do this in order to strengthen and support one another and our community. We can all work towards a new normal that can be better than the one we left behind. This is a moment in history where we can integrate ourselves back into society as supportive rather than oppressive.
A Word about Shame and Judgement
These are trying times. We are scared. Some of us are facing death and illness like never before in our lives. Shame is a powerful tool used to maintain conformity to a social standard. It works. It also causes death, depression, isolation, and deep suffering far greater than any virus ever could. Being judgemental about others' choices shuts people down from being honest. Not knowing what someone is doing during the age of coronavirus is potentially deadly. It is far better to know if someone is not following measures to reduce viral transmission, so that you can protect yourself, than to shame and judge them to where they don’t disclose that to anyone else (while not changing their behavior). Listening to their reasons and having an open discussion is far more effective to have them care about their choices.
Container:Who is in your current social circle?
The Container includes the people who are in your household, living space, work space, or whom you might interact with without social distancing or precautions. Some other terms used are circle, cohort, contact circle, COVID pod, COVID-bonded, germacule, droplet bonded,and primary community.
You could have a primary container — those that you share space with — and a secondary container, such as work spaces or visitors who have their own primary residences or containers. Those with bigger containers have bigger risks of infections associated with them.
Your container can have people at different social distances and include people who are in multiple containers. It should include the people who you directly intersect with: anyone who comes within 6 feet of you for more than 10 minutes. As time goes on, these containers may change, with people moving away or closer. Every shift requires new agreements from all in the primary container.
Many people know who is in their container, and feel safe within those choices, but many people do not have that privilege. Essential/front line workers, incarcerated, houseless and people in detention, have no say or ability to protect themselves from viral transmission. We have a social responsibility to them to understand our ability to make choices and continue to account for this when we begin to open up our container to others.
Who is in our container? What are their risks? How does our choice to engage with others affect them? Where does our container exist? A person living in New York City may feel very differently than someone living in rural Oregon.
The challenge is being able to communicate this to others. While it may seem like a hassle, drawing out your contacts can be a visual way to show others. This way, others can better make a decision knowing who is who and what they are willing to enter.
You can create your own Container diagram here to share with others.
Agreements: What agreements that you have with the people in your current container?
We often take people that we live with for granted. Maybe we have not clearly sat down and spoken our boundaries and risk reduction etiquette out loud, but have a common understanding of each other while we are in the place of “stay at home” measures. As we move towards broadening our containers, we need to create agreements with each other to help navigate these changes.
Everyone needs to understand and be clear about their needs and risks with everyone else within their container. Usually the highest risk person or the person with the lowest risk tolerance will set the standards of acceptable behavior for the container. Adding more people increases risks to everyone, so having clear agreements will be critical to everyone proceeding with caution and care.
Agreements may have allowances for those not at the same level. For example, if one person in the container socializes with others at less than 6 feet, the other members of the container may wish to stay more than 6 feet from them, and ask for extra cleaning of shared spaces or wearing of masks when near each other.
In some containers, it is difficult to have perfect risk reduction behaviors, such as maintaining 6 foot distance from strangers, wearing masks, or staying at home. For example families with essential/ frontline workers, teenage children or special needs people. In these situations, disclosure about the additional risks to others must be made as one broadens the social network. This is not about getting an infection that can easily be treated with an antibiotic, but something that can kill someone even with two degrees of separation.
Risk tolerance: What is your tolerance for risk for yourself and what are you putting onto others?
This is the most controversial and difficult place to navigate as we reduce social distancing and open society back up. We each have our own personal tolerance for illness, disease and death. It is imperative that we understand this in order to take into account everyone else in our container and community at large. This is why physical distancing is called for right now. It is the most effective means to reduce the spread of this virus. Yet, I cannot foresee a world where we no longer go to church, get our hair cut or see our friends and lovers. Humans are social creatures and connection to others is fundamental to life itself. Forsaking joy, love, pleasure and others for the period of time until herd immunity is reached will cause inordinate suffering.
Why consider risk tolerance and not just risks themselves?
Risk tolerance can dictate the behaviors we impart unconsciously to others. Risk tolerance is subjective and easily justified. We each form our risk tolerance based on our perceived personal and societal risks and benefits. We assume that everyone is on the same page (ours) or should be. We get angry and feel betrayed if they are not. Low or high risk tolerance does not make one better or worse, but with COVID-19, the need to be clear and conscious with one’s choices are imperative.
I use a backpack as a metaphor to explain the concept of risk tolerance: the more equipment (risks and precautions) you carry, the slower you move (lower tolerance), but the more likely you are to survive if you get lost in the woods (get infected). The less you carry, the faster you move (high tolerance) but the more likely you will be in need if you get lost.
People living in a high rise building in New York City will have a different risk tolerance than people in a farm community in rural Oregon. The more someone is at risk of disease and death due to where they live, their health, pre-existing conditions, economic status, race, or age, the lower their risk tolerance. Others feel that they have less to lose if they get sick, and are willing to take on more risks. One cannot know everyone’s level of vulnerability who we come in contact with. Essential workers and those they care for have died due to others’ inadvertent exposure.
Your personal risk tolerance is yours alone and cannot be imposed on anyone else without their clear verbal understanding and agreement. As risk tolerance increases, so does the potential harm to others. You are responsible for protecting others from yourself, otherwise that is a consent and boundary violation.
Understanding risk tolerance and being responsible for your choices is critical to our ability to open up our society as safely as possible.
As we open up our social containers to others, decreasing physical distance, not only risk tolerance should be clearly discussed but so should individual risk factors of all members. The person with the lowest risk tolerance and highest risk, must set the bar, without guilt or manipulation. If there are inconsistencies with this, then etiquette needs to be discussed and agreements made.
The following scale is not inclusive of all situations and is just a guide for defining one's own risk tolerance level. Circumstances such as being an essential worker or one’s job, may make it difficult to be in the category that one wishes to be in. People may straddle different categories or move between them due to jobs, members in their containers, and results of available tests. There is no judgement implied in this; stricter levels of risk tolerance are not inherently “better” or “worse” than less strict levels. The intent here is to create a common vocabulary so we can communicate where we each stand.
0: Very Strict — Have been in very strict isolation alone or with others in a container, which may include the following:
● Stays exclusively within the container/household.
● 6 feet apart with others within the household/container.
● Strict etiquette including hand washing, masks and social distancing are used 100% of the time within the container.
● Groceries delivered and wiped down.
● No one outside is allowed in.
● Infection control protocols outside of the bedroom. Bleach or sanitizing all surfaces touched by more than one person, no shared bathroom spaces.
People in this category are most likely to be at the highest risk of death from contracting the disease or caring for those that are. They may be on chemotherapy, immunosuppressives, elderly, pre-existing medical conditions (hypertension, diabetes, heart disease, etc), people of color, etc.
Their risks of sickness can interfere with their quality of life. Areas of high density of people, such as a city, may need this level of tolerance for the foreseeable future, until adequate testing and contact tracing is readily available. People in this category may have a lot of fear, value social responsibility towards others, and/or want to flatten the curve. Wanting to get through this pandemic without illness to self or others is a strong priority.
1: Strict — Have been in strict isolation alone or with others in a container, which may include the following:
● Does not optionally leave the house/container except to get groceries and go to work.
● No social distancing with members of one’s container.
● Strict etiquette including hand washing, masks and social distancing are used 100% of the time when outside of the container.
● Groceries delivered and/or wiped down before being allowed into the container.
● No visitors are brought inside the container.
● Person to person connection is done virtually or across a wide berth >6 ft + masks.
For some, while they may want to be at this level, they cannot due to their societal, economic, and/or personal situation. Essential workers may be strict when they are able to make those decisions but their work puts them at higher risk, so their risk tolerance is higher than their desire.
2: Fairly Strict — Have been in fairly strict isolation alone or with others in a container, which may include the following:
● Leaves the house to go to work, where etiquette to reduce transmission is not strictly available.
● Fairly strict etiquette including hand washing, masks, and social distancing are used 80-100% of the time when outside of the container.
● Minimizes grocery and other shopping (once a week or less).
● Brief outdoor exercise in low density areas.
● May socialize with others outside of the container, at 6 ft apart or less than 6 ft with masks.
● No sexual activity with anyone outside of the container. (Sexual activity is any behavior where sexual touch is exchanged.)
● No one in the container has prolonged (more than 10 minutes) exposure with those outside the container.
People in this category may need more social exchange with others but still want to reduce the risks of infection as much as possible. Other circumstances, such as needing to continue work or take care of someone outside of the primary container, may require this level of risk tolerance.
3: Somewhat Open — Have chosen to be somewhat open with their container alone or with others, which may include the following:
● Leaves the container to exercise, go to the store, work and other activities several times a week.
● Etiquette including hand washing, masks and social distancing are used about 80% of the time when outside of the container.
● Sometimes socializes with others who are not in one’s container
○ Maintains social distance
○ Less than 10 people
○ No more than twice a week.
● Sometimes socializes with others at less than a 6 foot distance if they have been following fairly strict or somewhat open protocols as well.
● May engage in sexual activity with others only if they have also have similar risk tolerance, with consent. Sexual activity is limited to no exchange of bodily fluids including open mouth kissing and oral sex.
People in this category may be found in places with lower Covid infections.
Those who have lower risk of death and disease to themselves, and do not share space with others at high risk, may be in this category.
4: Moderately Open — Have chosen to be moderately open with their container alone or with others, which may include the following:
● Leaves the container to exercise, go to the store, work, and other activities multiple times a week.
● Etiquette including hand washing, masks and social distancing are used around 40-60% of the time when outside of the container.
● Regularly socializes others who are not in one’s container
○ May not maintain social distance
○ More than 10 people
○ No regard to how often one socializes.
● May engage in sexual activity with others only if they have also have similar risk tolerance, with consent. Sexual activity can include exchange of bodily fluids including open mouth kissing and oral sex.
People here may believe they have no risk factors, or do not believe they know anyone who is at risk if they get the infection, or may be wanting to get infected.
They may have already been infected, tested positive for antibodies, and feel sure that they are no longer a vector for infecting others. Please note, that at the time of this writing, we do not know whether having antibodies to SARS-CoV-2 imparts immunity.
5: Very Open
● Leave the container to exercise, go to the store, work and other activities multiple times a week with no precautions that have been shown to reduce viral transmission.
● Etiquette including hand washing, masks and social distancing are used about 0-40% of the time when outside of the container.
● Regularly socializes with others who are not in one’s container
○ Does not maintain social distance
○ More than 10 people
○ No regard to how often one socializes.
● Engages in sexual activity with others only if they have also have similar risk tolerance, with consent. Sexual activity can include exchange of bodily fluids including open mouth kissing and oral sex.
Some people desire infection, have tested positive for antibodies, or do not want to be told what to do.
Anyone with this risk tolerance has the social responsibility to take strong precautions from possibly infecting others who may be vulnerable, including essential workers.
Etiquette: What code of socially responsible behaviors do you agree to?
As members of a greater community, the choices we make will help support one another. Some of these choices are based on hard science, such as hand washing protocols. Others we are still figuring out, such as the benefits of wearing masks.
Etiquette is something we do for each other and for the benefit of society as a whole. There are expectations that we behave in a way that reduces the risk of contracting COVID-19 not only to ourselves but to those that do not have a choice in their interactions with us. We are not only taking on reducing risks for ourselves, but on how we are imposing on each other.
Shame has no role in helping us stay together. Shame tears ourselves and each other apart. Rather than using shame as a tool to encourage conformity, I recommend using accountability and communication.
Clean hand protocol — Wash your hands often with soap and water for at least 20 seconds, especially after you have been in a public place, or after blowing your nose, coughing, or sneezing.
If soap and water are not readily available, use a hand sanitizer that contains at least 60% alcohol. Cover all surfaces of your hands and rub them together until they feel dry.
Avoid touching your eyes, nose, and mouth with unwashed hands.
Secure Shared Space — Determined by those within a container. This may be a place where you do not feel the need to have strict measures such as wiping down surfaces after touch, wearing gloves, or covering your face.
Physical (social) distance — 6 feet is an old determination that has been the set standard for shared air space. Previous studies, using aircrafts as a model, have determined that this is the distance needed to avoid sharing small droplets. However, a sneeze or cough can carry viral particles much further.
Covering your coughs and sneezes—All coughs and sneezes, even if they are due to environmental allergies, need to be covered. The ideal is a clean paper tissue that is immediately thrown away into a closed container. Hands need to be washed or use of hand sanitizer immediately afterwards.
Masks — Are worn to protect others from you, not the other way around. Wearing a mask in public can have an overall impact of slowing down the transmission of the virus. The CDC does recommend the use of a mask, even a plain cloth mask, whenever you are out in public. If everyone was to wear a mask in public, it reduces the inadvertent transmission of people who may be asymptomatic as well.
See this good NYTimes article for further information: A User's Guide to Face Masks
Gloves — Are not well recommended since some people use the wearing of gloves to touch anything. Gloves can give a false sense of protection. If you are going to wear gloves, they must be put on after a 20 second hand wash or use of alcohol sanitizer. Do not touch your face with your gloved hand or you will self contaminate.Take off the gloves as soon as they are no longer needed. Pull one off first, then use the clean hand to go under the glove to pull the other one off. Do not reuse them and dispose of them in a closed container.
Sex — The virus lives in saliva, any exchange of bodily fluids carries a risk of transmission. The virus has been found in stool, so any anal play can transmit the virus to your respiratory passages (mouth) and should be avoided unless you are in a mutually monogamous container with them. Sexual activity is not limited to exchange of bodily fluids and this might be a chance
to discover the array of sensual and intimate activities that are available to us.
We are in a time of great uncertainty. We do know, for those that believe in data and science, that social distancing, adequate hand washing, and stay at home measures have reduced the transmission of SARS-CoV-2 virus. Until accurate testing is widely available and contact tracing set up, these are the best measures we have to decrease morbidity and mortality due to COVID-19. Unfortunately, there isn’t a clear end in sight. Rather than despair, we need to find a way to proceed forward with grace and compassion. Communication with those in your day to day life, having clear agreements to meet everyone’s needs, and understanding your conscious and unconscious behavior will be critical as we begin to open up our society. Until we have what we need to safely relax social restrictions, talking with those in your container/circle is one small tool that can go a long way as we prepare to ride out this storm together. We each can work towards creating a new “normal” where we learn to be self aware, responsible and care for one another.
Other Notes and Sources:
There is still a lot we don’t know about and the tests are still not accurate enough to be reliable.
At this time we have two tests that are available:
● Viral test — to check if you have a current Covid infection. There is up to a 30% false negative rate in some of the tests.
● Antibody test — to check if you have antibodies to the virus. This tells us that you have some immunity to the virus. We don’t yet know that just because someone has developed antibodies, that they are fully protected from reinfection, or how long any immunity lasts.
I see many tests being offered that have not yet been FDA approved and there is no available data on their accuracy.
“The top Covid-19 comorbidities listed by New York, in order, are hypertension, diabetes, high cholesterol, coronary artery disease, dementia, and atrial fibrillation, a heart condition. Chronic obstructive pulmonary disease, another respiratory ailment, but one with an older demographic than asthma, ranks seventh. Renal disease, cancer and congestive heart failure round out the list.” NY Times
For those who choose to wear a mask, watch this demonstrated in a WHO video, the key is to not to touch the outside of the mask — and to wash your hands if you do.
Evelin Dacker MD is an Integrative Family Physician in Salem, Oregon.