I recently took a drive-through COVID-19 test at the University of North Carolina. Everything was well organized and efficient: I was swabbed for 15 uncomfortable seconds and sent home with two pages of instructions on what to do if I were to test positive, and what precautions people living with or tending to COVID-19 patients should take. The instructions included many detailed sections devoted to preventing transmission via surfaces, and went into great detail about laundry, disinfectants, and the exact proportions of bleach solutions I should use to wipe surfaces, and how. My otherwise detailed instructions, however, included only a single sentence on “good ventilation”—a sentence with the potential to do some people more harm than good. I was advised to have “good air flow, such as from an air conditioner or an opened window, weather permitting.” But in certain cases, air-conditioning isn’t helpful. Jose-Luiz Jimenez, an air-quality professor at the University of Colorado, told me that some air conditioners can increase the chances of spreading infection in a household. Besides, “weather permitting” made it all seem insignificant, like an afterthought. While waiting for my results, I checked the latest batch of announcements from companies trying to assure their customers that they were doing everything right. A major U.S. airline informed me how it was diligently sanitizing surfaces inside its planes and in terminals many times a day, without mentioning anything about the effectiveness of air circulation and filtering inside airplane cabins (pretty good, actually). A local business that operates in a somewhat cramped indoor space sent me an email about how it was “keeping clean and staying healthy,” illustrated by 10 bottles of hand sanitizer without a word on ventilation—whether it was opening windows, employing upgraded filters in its HVAC systems, or using portable HEPA filters. It seems baffling that despite mounting evidence of its importance, we are stuck practicing hygiene theater—constantly deep cleaning everything—while not noticing the air we breathe. [Read: Paging Dr. Hamblin: Should I fly?] How is it that six months into a respiratory pandemic, we still have so little guidance about this all-important variable, the very air we breathe? The coronavirus reproduces in our upper and lower respiratory tracts, and is emitted when we breathe, talk, sing, cough, or sneeze. Figuring out how a pathogen can travel, and how far, under what conditions, and infect others—transmission—is no small deal, because that information enables us to figure out how to effectively combat the virus.For COVID-19, perhaps the most important dispute centers specifically on what proportion of of what size droplets are emitted from infected people, and how infectious those droplets are, and how they travel. That the debate over the virus’s modes of transmission is far from over is not a surprise. It’s a novel pathogen. The Columbia University virologist Angela Rasmussen told me that, historically, it took centuries to understand how pathogens such as the plague, smallpox, and yellow fever were transmitted and how they worked. Even with modern science, there are still debates about how influenza, a common annual foe, is transmitted. In particular, the size of infectious particles really matters, because that determines how they travel—are they big enough to be quickly pulled down by gravity or are they small enough to float around? Since the beginning of the pandemic, the World Health Organization has considered the primary mode of COVID-19 transmission to be respiratory droplets. These droplets are defined as particles bigger than 5 to 10 microns in diameter, and WHO guidelines say that once they are sprayed out of someone’s mouth, they travel ballistically and fall to the ground within close range of the infected person. For the WHO, that range is about three feet; for the Centers for Disease Control and Prevention, which also considers droplets to be the primary mode of transmission, it’s six feet. The dominance of a ballistic-droplet mode of transmission in this pandemic would mean that we should focus mostly on staying out of droplets’ range, especially to prevent them from falling on our unprotected mouth, nose, and eyes—hence the social-distancing guidelines. It also would mean that keeping that distance would be enough to stay safe from an infected person, on the other side of a room for example. (Of course, our hands can still potentially pick them up from surfaces and bring them to our face, hence the importance of hand-washing.) There is a big dispute in the scientific community, however, about both the size and the behavior of these particles, and the resolution of that question would change many recommendations about staying safe. Many scientists believe that the virus is emitted from our mouths also in much smaller particles, which are infectious but also tiny enough that they can remain suspended in the air, float around, be pushed by air currents, and accumulate in enclosed spaces—because of their small size, they are not as subject to gravity’s downward pull. Don Milton, a medical doctor and an environmental-health professor at the University of Maryland, compares larger droplets “to the spray from a Windex dispenser” and the smaller, airborne particles (aerosols) “to the mist from an ultrasonic humidifier.” Clearly, it’s enough to merely step back—distance—to avoid the former, but distancing alone would not be enough to avoid breathing in the latter. [Read: Paging Dr. Hamblin: Can AC spread the coronavirus?] The disagreement got heated enough that earlier this month, hundreds of scientists around the world signed a letter, pleading with the WHO to acknowledge these smaller particles as an extra mode of transmission and to update its guidelines accordingly. Some experts I spoke with told me that they had been trying to convince the WHO to take the possibility of airborne transmission since March, and that the open letter was borne out of frustration about lack of progress. Signatories who study aerosols—the smaller, floating particles—including professor Linsey Marr of Virginia Tech and Jimenez, told me that they don’t disagree with the idea that transmission at close range represents the most risk, as per the WHO and CDC guidelines. But they disagree that the dominance of close-contact transmission implies that ballistic trajectories or larger respiratory droplets are the overwhelming mode of transmission. In their view, even some portion of that close-contact transmission is likely due to aerosols, and many experts told me that they think even particles bigger than the WHO’s definition of respiratory droplets (larger than 5-10 microns in diameter) can float for a bit. In response, the WHO published a scientific brief on July 9 acknowledging the possibility of airborne transmission, but still concluding that COVID-19 is “primarily transmitted” between people through respiratory droplets and touching, and that the question needs “further study.” Part of the difficulty with this discussion has been that the relevant experts, including infectious-disease specialists, epidemiologists, environmental and aerosol engineers, don’t even agree on the terminology. The particles we emit from our mouths can be called droplets, microdroplets, droplet nuclei (particles that start out bigger but get smaller because of evaporation) or aerosols.There is no clear line between big and small particles and droplets and aerosols; it’s a continuum with complex aerodynamics depending on the environment, and to make matters worse, the same word—like aerosol—sometimes means something different in each field. The terminological confusion led Milton to write a “Rosetta Stone” paper to try to clarify the terms across fields. For this article, I’ll call the spray-borne particles that travel ballistically “droplets,” and the ones that can float “aerosols” (regardless of what size the particles may be, as the key question is whether they can float and be pushed around by air—and that size cut-off remains disputed). Plus, this debate has a long history: From the mid-19th century into the 20th century, infectious-disease specialists fought a long and hard-won battle against “miasma” theories of disease that posited that filth and noxious odors, instead of germs, were responsible for disease. In a seminal 1910 book, the public-health pioneer Charles Chapin distinguished “spray borne” diseases (WHO’s droplets that maximally travel only a few feet) from “dust borne” ones—spread by aerosols, or airborne transmission. He concluded that most pathogens were either “spray-borne” or spread through contact, and worried that an over-reliance on “air-borne” theories would needlessly scare the public or cause them to neglect hand-washing. More than a century later, there are still echoes of those concerns. There are also different kinds of “airborne” transmission—the term can sound scarier than reality and can become the basis for unnecessary scaremongering. For example, some airborne diseases, such as measles, will definitely spread to almost every corner of a house and can be expected to infect about 90 percent of susceptible people in the household. In the virus-panic movie Outbreak, when Dustin Hoffman’s character exclaims, “It’s airborne!” about Motaba, the film’s fictional virus, he means that it will spread to every corner of the hospital through the vents. But not all airborne diseases are super contagious (more on that in a bit), and, for the most part, the coronavirus does not behave like a super-infectious pathogen. [Read: Is the coronavirus airborne? Should we all wear masks?] In multiple studies, researchers have found that COVID-19’s secondary attack rate, the proportion of susceptible people that one sick person will infect in a circumscribed setting, such as a household or dormitory, can be as low as 10 to 20 percent. In fact, many experts I spoke with remarked that COVID-19 was less contagious than many other pathogens, except when it seemed to occasionally go wild in superspreader events, infecting large numbers of people at once, across distances much greater than the droplet range of three to six feet. Those who argue that COVID-19 can spread through aerosol routes point to the prevalence and conditions of these superspreader events as one of the most important pieces of evidence for airborne transmission. Saskia Popescu, an infectious-disease epidemiologist, emphasized to me that we should not call these “superspreaders,” referring only to the people, but “superspreader events,” because they seem to occur in very particular settings—an important clue. People don’t emit an equal amount of aerosols during every activity: Singing emits more than talking, which emits more than breathing. And some people could be super-emitters of aerosols. But that’s not all. The superspreader-event triad seems to rely on three V’s: venue, ventilation, and vocalization. Most superspreader events occur at an indoor venue, especially a poorly ventilated one (meaning air is not being exchanged, diluted, or filtered), where lots of people are talking, chanting, or singing. Some examples of where superspreader events have taken place are restaurants, bars, clubs, choir practices, weddings, funerals, cruise ships, nursing homes, prisons, and meatpacking plants. Strikingly, in one database of more than 1,200 super-spreader events, just one incident is classified as outdoor transmission, where a single person was infected outdoors by their jogging partner, and only 39 are classified as outdoor/indoor events, which doesn’t mean that being outdoors played a role, but it couldn’t be ruled out. The rest were all indoor events, and many involved dozens or hundreds of people at once. Other research points to the same result: superspreader events occur overwhelmingly in indoor environments where there are a lot of people. [Read: How air-conditioning invented the modern world] Benjamin Cowling, the head of epidemiology and biostatistics at the University of Hong Kong School of Public Health, points to a case at a restaurant in Guangzhou where a yet asymptomatic COVID-19 patient infected nine other people, many of whom were sitting at other tables but were in the direct line of the air-conditioner, which was blowing air from one end of the restaurant to the other. Tables right next to the patient’s but not downwind did not have a single infected person, and close-circuit camera videos from the day show that the people at the infected tables didn’t interact with the patient at all. It was the air. Cowling’s colleagues analyzed the fluid dynamics of that outbreak, showing that the air-conditioner blew the air in one direction, where it hit a wall, recirculated back, and was pushed out again, basically trapping the unlucky tables downwind, with the infected air going “round and round and round,” as Cowling described it to me. In another superspreader event, at a choir practice of 61 people in Skagit, Washington, a single patient caused 32 confirmed and 20 likely COVID-19 cases—almost everyone in the room. In another striking case, at a Korean call center, where people talk all day, 94 out of 216 people on one floor of the building were infected, with cases clustered on one side of the floor but some as far as 20 desks away from each other, with a few as far away as the opposite wall. Only three people on other floors were infected, despite the employees sharing a lobby and elevators, reinforcing that surfaces aren’t efficient transmitters, but that shared air pockets can be, almost regardless of distance. For these superspreader events, Milton says you have to “really jump through hoops to argue that they were anything other than transmitted by air”. But it’s not only COVID’s superspreader events that are indoors. Rest of the pattern of spread of COVID —when it is spreading slowly, in small numbers—is also overwhelmingly through indoor transmission. Milton told me that if those sprayed droplets were the primary means of transmission, we would expect to see more transmission outdoors, since the droplets are being ejected with some force and falling on people, but that doesn’t seem to be the case. Even if sunlight, which can deactivate viruses, were dampening transmission outdoors, one would at least expect to see a lot more outdoor transmission than we are seeing now. Instead, epidemiologists are finding that this disease stalks us indoors. There is also evidence from healthcare settings. Hitoshi Oshitani, a virology professor at Tohoku University Graduate School of Medicine in Japan, told me that quarantine officers on the Diamond Princess cruise ship who followed standard precautions against droplets and close contact, nonetheless got infected anyway. This was an important clue for Japanese scientists about the importance of aerosols. “Those were professionals,” he said. For him, that meant that it was unlikely they slipped up, and more likely that the disease acted in ways they weren’t prepared for. A recent (preprint) paper showed that health-care workers in the United Kingdom—where hospitals are older and ventilation measures are poorer--were getting sick at higher rates than those in the United States where many hospital buildings come with ventilation mitigation measures. And in a peer-reviewed paper, just published at Nature, researchers reported finding viral RNA in more than half the air samples in a hospital, including outside the patient rooms and the hallways. While it remains a question how infectious those particles may have been, Marr told me that it was significant that “100% of samples from floor under the bed and all but one window ledge were positive for viral RNA, indicating that the virus was transported through the air and settled onto these surfaces.” However, to date, there is also no evidence of truly long-range transmission of COVID-19, or any pattern of spread like that of measles. Screaming “it’s airborne!” can give the wrong impression to an already weary and panicked public, and that’s one reason that some public-health specialists have been understandably wary of the term, sometimes even if they agreed aerosol transmission was possible. Cowling told me that it’s better to call these “short-range aerosols,” as that communicates the nature of the threat more accurately: Most of these particles are concentrated around the infected person, but, under the right circumstances, they can get accumulate and get around. All this has many practical consequences. As Marr, from Virginia Tech, says, if aerosols are crucial, we should focus as much on ventilation as we do on distancing, masks, and hand-washing, which every expert agrees are important. As the virologist Ryan McNamara of the University of North Carolina told me, all these protections stack on top of one another: The more tools we have to deploy against COVID-19, the better off we are. But, it’s still important for the public to have the correct mental model of the reasoning behind all the mitigations, since even those agreed-upon protections don’t all behave the same way under an aerosol regime. [Read: The moral history of air-conditioning] For example, current WHO guidelines don’t recommend masks indoors if a distance of one meter can be maintained. Similarly, the CDC makes scant reference to the distinction between indoor and outdoor transmission in its mask guidance, and recommends masks in public settings, “especially when other social distancing measures are difficult to maintain.” However, an aerosol regime would suggest that distancing isn’t as protective indoors as one would hope, especially since people eating and drinking tend to be talking while unmasked. (The CDC seems to recognize this when it recommends hosting gatherings outdoors, though it still officially stresses transmission through droplets). Under an aerosol regime, we would have different rules for the indoors and the outdoors (especially since, in addition to the diluting power of air, sunlight quickly deactivates viruses.) We would mandate masks indoors regardless of distancing, but not necessarily outdoors. Marr told me that she wears her mask outdoors only if she’s interacting with people, if she’s in a crowd, or if she cannot maintain distance. Yet, in the United States, many locales are mandating masks indoors and outdoors under the same rules, forcing even the solitary person walking her dog to mask up. And there are places, such as Chicago, where beaches are closed because officials fear crowds, but indoor restaurants and gyms remain open with mild restrictions. As another example, you may have seen the many televised indoor events where the audience members are sitting politely distanced and masked, listening to the speaker, who is the only unmasked person in the room. Jimenez, the aerosol expert, pointed out to me that this is completely backwards, because the person who needs to be masked the most is the speaker, not the listeners. If a single mask were available in the room, we’d put it on the speaker. This is especially important because cloth masks, while excellent at blocking droplets (especially before they evaporate and become smaller, thus more likely to be able to float), aren’t as effective at keeping tinier aerosol particles out of the wearer’s mouth and nose once they are floating around the room (though they do seem to help). We want to see the speaker's mouth, one might say, but that is a problem we can approach creatively—face shields that wrap around the head and seal around the neck, masks with transparent portions that can still filter, etc.—once we stop ignoring the problem. In fact, designing a high-filtration but transparent mask or face shield might be an important solution in classrooms as well, to help keep teachers safe. Once we pay attention to airflow, many other risks look different. Dylan Morris, a doctoral candidate at Princeton and a co-author of the first paper to confirm that the virus could remain infectious in aerosolized form, under experimental conditions, showed me a clip of a group of people in a conga line, separated six feet apart by ropes. They were merrily dancing, everyone standing behind someone else, in their slipstream—exactly where you don’t want to be, inhaling aerosol clouds from panting people. Similarly, Jimenez pointed out that, when a masked person is speaking, the least safe location might be beside them or behind them, where the aerosols can escape from the mask, though ordinarily, under a droplet regime, we would consider the risk to only be in front of them. The importance of aerosols may even help explain why the disease is now exploding in the southern United States, where people often go into air-conditioned spaces to avoid the sweltering heat. Finally, all this would have implications for people around COVID-19 patients, especially in the community. In U.S. health-care settings, precautions against aerosols are usually already in place, partly because health-care workers undertake procedures—such as intubation—that generate aerosols even if a disease isn’t very prone to creating them. (Most COVID-19 guidelines, including from the WHO and the CDC, from the beginning acknowledged aerosols to be a risk in health-care settings because of such procedures; the dispute has always been whether aerosol transmission occurs organically in everyday settings). However, in the community, accepting aerosol risks would mean that people around COVID-19 patients at home or anyone high-risk, such as the immunocompromised, should at least be provided with higher-grade masks such as N95s, which do a better job of keeping aerosols out. There are two key mitigation strategies for countering poor ventilation and virus-laden aerosols indoors: We can dilute viral particles’ presence by exchanging air in the room with air from outside (and thus lowering the dose, which matters for the possibility and the severity of infection) or we can remove viral particles from the air with filters. Consider schools, perhaps the most fraught topic for millions. Classrooms are places of a lot of talking; children are not going to be perfect at social distancing; and the more people in a room, the more opportunities for aerosols to accumulate if the ventilation is poor. Most of these ventilation issues are addressable, sometimes by free or inexpensive methods, and sometimes by costly investments in infrastructure that should be a national priority. Last week, I walked around the public elementary school in my neighborhood while thinking about what we could do if we took aerosol transmission more seriously. It’s a single-story building, all the classrooms have windows, some have doors that open directly to the outside, and many have a cement patio right outside. Teaching could move outdoors, at least some of the time, the way it did during the 1918 pandemic. Moreover, even when indoors or during rainy days, opening the doors and windows would greatly improve air circulation inside, especially if classrooms had fans at the windows that pushed air out. [Read: Why can’t we just have class outside?] When windows cannot be opened, classrooms could run portable HEPA filters, which are capable of trapping viruses this small, and which sell for as little as a few hundred dollars. Marr advises schools to measure airflow rates in each classroom, upgrade filters in the HVAC system to MERV 13 or higher (these are air filter grades), and aspire to meet or exceed ASHRAE (the professional society that provides HVAC guidance and standards) standards. Jimenez told me that many building-wide air-conditioning systems have a setting for how much air they take in from outside, and that it is usually minimized to be energy-efficient. During a pandemic, saving lives is more important than saving energy, so schools could, when the setting exists, crank it up to dilute the air (Jimenez persuaded his university to do that). Jimenez also wondered why the National Guard hadn’t been deployed to set up tent schools (not sealed, but letting air in like an outdoor wedding canopy) around the country, and why the U.S. hadn’t set up the mass production of HEPA filters for every classroom and essential indoor space. Instead, one air-quality expert reported, teachers who wanted to buy portable HEPA filters were being told that they weren’t allowed to, because the CDC wasn’t recommending them. It is still difficult to get Clorox wipes in my supermarket, but I went online to check, and there is no shortage of portable HEPA filters. There is no run on them. Some countries have already bucked the trend of ignoring short-range aerosols. Oshitani told me that in Japan, researchers took short-range aerosol transmission seriously from the start, and focused on the few transmission events that spread the disease to large numbers of people at once. Cowling, of Hong Kong University, told me the same thing: He considers short-range aerosols and superspreader events to be key to the spread of COVID-19. Japan was expected to fail by many, as it implemented an unconventional response, bucking WHO guidelines, eschewing widespread testing, and forcing few formal lockdowns. However, Japan masked up early, focused on superspreader events (a strategy it calls “cluster busting”), and, crucially, trained its public to focus on avoiding the three C’s—closed spaces, crowded places, and close conversations. In other words, exactly the places where airborne transmission and aerosols could pose a risk. The Japanese were advised not to talk on the subway, where windows were kept open. Oshitani said they also developed guidelines that included the importance of ventilation in many different settings, such as bars, restaurants, and gyms. Six months later, despite having some of the earliest outbreaks, ultradense cities, and one of the oldest populations in the world, Japan has had about 1,000 COVID-19 deaths total—which is how many the United States often has in a single day. Hong Kong, a similarly dense and subway-dependent city, has had only 24 deaths. To be clear, the science concerning aerosols isn’t settled, which is acknowledged by the signatories of the letter to the WHO urging recognition and mitigation of possible aerosol risks. Rasmussen, the Columbia virologist, could easily rattle off many things she’d like to know about airborne transmission: how much infectious virus is in a given droplet, if some people shed a lot more of the virus than others, or, at what point in their infection, if the virus is more concentrated in the droplet nuclei and what constitutes an infectious dose. But facing a pandemic, we have to act with imperfect information. The letter writers stress that “we must address every potentially important pathway to slow the spread of COVID-19,” even if evidence is incomplete, especially since some of the measures are as simple as opening a window and moving outdoors. This is especially crucial because mitigations stack: The more we have available, the more effective they become. In this period when we don’t have all the answers, much is at stake. My COVID-19 test was negative, so I didn’t need to worry about that, but I wonder about the alternate world, where we take aerosols seriously, had I tested positive, I would have been sent home with firm instructions on opening windows, a loaner HEPA filter, N95 masks for my housemates, and strong warnings not to assume that staying six feet away from me was enough. Marr told me that she “sheepishly” switched her elementary- and middle-school-age children to a private school because she was able to make a case with the school to take “good ventilation” seriously, in addition to wearing masks and social distancing. Not every school will have such resources, but maybe providing those resources is exactly what we should aspire to for all schools. If the signatories of the letter to the WHO are correct, then adding ventilation to our mitigation stack is exactly what we should focus on, doing everything necessary ranging from the more expensive upgrades to our air-quality infrastructure to opening the windows that are right within our reach. from https://ift.tt/3hV3GQ5 Check out http://natthash.tumblr.com
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On this episode of the podcast Social Distance, staff writer Graeme Wood makes his first visit to Walt Disney World in the midst of a pandemic. Listen to the episode here: Subscribe to Social Distance on Apple Podcasts, Spotify, or another podcast platform to receive new episodes as soon as they’re published. What follows is an edited and condensed transcript of their conversation. Katherine Wells: Why did you go to Disney World? Graeme Wood: One reason is that I’d never been there before. And I was never gonna go there. I had no interest in going to Disney World. But right now it is a really fascinating place, because it’s where a lot of people get together and have to deal with the effects of a pandemic and decide that it’s worth the risk. Wells: Walk us through your experience there a little bit. Wood: The Disney experience is an all-encompassing one. When you arrive at Orlando Airport, you get sent into the Disney bubble and you don’t really emerge until almost the moment you get on your flight to go home. That’s what happened with me. I got onto the Disney bus at the Disney area of the airport, went to a Disney resort, and all I did during the day was eat at Disney restaurants and go to Disney parks. My experience was full Disney for four days. Wells: Was it crowded? Wood: I have to adjust my priors a bit because I’ve never been to Disney World before. I know lots of people who have, and what they always talk about are the crowds and the expense. If you go there now, the crowds are relatively thin. You can walk down the street without bumping into people, and you can go on rides and attractions without having to wait for hours and hours. I think a normal person who knew Disney World and was going there for the second or third time would say it looks like a neutron bomb has hit the place and it’s being repopulated slowly by a trickle of visitors. Wells: What did the people who were there think about it? Did they find it eerie? Wood I think that most of them were having a really good time. It’s a little bit hard to tell because you’re looking at people in masks, which is weird. This is a place where everybody is supposed to be having a good time at all times. It’s compulsory. But you don’t see a human face, let alone a human smile, the whole time. James Hamblin: Who was there? Wood: To me, a shocking range of people. I wore a button at the park that they give you if it’s your first time there and it says first-time visitor. I’m sure I was the only one at the park wearing that, because not many other people were thinking, Disney is opening after a pandemic that’s killing hundreds of thousands of people in this country, so I think I’ll go for the first time. It was the people who have wanted to go to Disney World for months who have been prevented from it. And who feel like it’s that important to go, because they love it so much. Wells: How were the rules enforced? If you were to get really close to someone or take off your mask, what happens? Wood: There are Disney employees, always referred to by Disney as “cast members,” who will come up to you and say, Oh, could you please put on your mask or Could you please raise your mask over your nose? They’ll say it in the nicest possible way. But in truth, I almost never in my whole time there—four days—saw someone who had to be reminded of that. What was really shocking and actually gratifying and pleasing to see was the level of compliance of guests. Everybody was just following the rules. And they were doing it, I think, in a spirit of harmony and goodwill and also respect for the authority of Disney World. It’s hard to exaggerate the difference being in that bubble and the rest of the world. Or the rest of America. Or even the rest of the famously unruly state of Florida, which literally surrounds Disney World. When you get to Disney World, you immediately find yourself in something that just doesn’t feel like America. It has a really good public-transportation system. It has a level of invasion of your privacy that Americans wouldn’t abide in other contexts. That is, you put on what’s called a Magic Band, kind of a Fitbit-like thing around your wrist, and anytime you walk past a sensor, Disney knows you were there. And they don’t hesitate to tell you that later by showing you a photograph of yourself there. Wells: Wait, so they’re tracking you and photographing you the whole time. Wood: All the time. And they’re doing that with your consent, I suppose. I put that band on and I was able to pay for things. You don’t even have to bring your credit card with you! You just tap your wrist against the sensor. And then when you get on one of the rides, they take a picture of you and they send you a copy of it because your Magic Band was on your wrist when you walked past a turnstile and they recognized that you were there. This is the kind of thing that if the federal government of the United States said, We’re going to watch you everywhere and take pictures of you—even if they offered me copies of those photographs, I would be pretty upset by that. But in Disney World, it felt more like having a contract-tracing app, like they have in Singapore. Now, Disney World is not actually using it that way, yet. But when I say that Disney World feels like another country, that’s what I mean. It feels like you’ve entered a space where the authorities have a huge amount of credibility. And in some ways, it resembles a quasi-benevolent authoritarian state rather than the malfunctioning anarchy that we have in this country. Wells: You have traveled the world and seen many different kinds of governments at work. What does it mean that inside the walls of Disney there was a more functional government than there is on the outside? Wood: I’m depressed by what I think are the inferences that we should gather from that. My understanding from this trip is that we had a lot of people who in other contexts just wouldn’t have trusted the authorities to manage the pandemic and wouldn’t do what they were told to do. And in this context, they have a huge amount of confidence in Disney to manage things. I think that’s a dark thought because with the loss of confidence in public institutions, private institutions rise to take that place. from https://ift.tt/2D2muOl Check out http://natthash.tumblr.com Editor’s Note: Every Wednesday, James Hamblin takes questions from readers about health-related curiosities, concerns, and obsessions. Have one? Email him at [email protected]. Dear Dr. Hamblin, My grandmother recently lost her husband and son, and was in a car accident that broke her hip and back. Because she has significant hearing and vision loss, she was told she would never be able to drive again. She is in her late 80s, is underweight, and lives with many chronic health issues, including heart disease, kidney disease, colitis, and anemia. She’s also understandably depressed in light of her personal situation and the pandemic, which has made her more lonely living in an already-isolated rural area. So I moved to Virginia to serve as her caretaker. I’ve done my best to keep her as safe as possible. We go to the park, have socially distanced visits with friends in their backyards, and pick up to-go orders from her favorite restaurants and wineries. The only thing I’ve refused to do for her is take her to the hair stylist. I understand that getting her hair done is important for her emotional and social well-being, something she’s done every week for as long as I can remember. But I just couldn’t in good conscience put her in a situation that I believed was dangerous. For a while, she was satisfied with my weekly hair washing and curling, but when our state reopened hair salons, that changed. Yesterday, she called me “mean” for refusing to take her. As a first-time caretaker, I’m really struggling with this. How should I strike a balance between her quality of life and her safety? Lauren Krouse Bridgewater, Virginia This is a beyond-difficult time for caregivers. The job was intense and mostly thankless even before the pandemic, but now, caring for a frail octogenarian means you have to think about everything you do as something that puts the person at risk. You and others in similar positions deserve more credit than I can begin to express here. No matter how much you love your grandmother, or anyone, isolating together can bring tension to a boil in ways that wouldn’t happen in normal times. So I hope it’s helpful to hear this: Let your grandmother get her hair done. Make sure she and her stylist and anyone else involved take proper precautions. Make sure she understands that even with precautions in place, there are still risks involved—not only of her getting the virus, but of you getting it, too. If she still insists, take her to the salon, and know that you’re doing the right thing, because it’s what she wanted. [Read: ‘We’re literally killing elders now’] I know that goes against your basic instincts as a caregiver. You didn’t move to Virginia so you could drive your grandmother to the salon for her to get a disease from which she’d have a high likelihood of dying. But we should be clear that what you’re describing is—from a purely medical perspective—a woman approaching the final years of her life. This is always uncomfortable to acknowledge, but it’s important to do because it informs how to make these types of decisions. A common tendency in these situations is wanting to swoop in and do everything in our power to keep a person physically healthy and, well, alive for as long as possible. But in the process we run the risk of denying agency to elders. Just because people aren’t able to drive, cook, or care for themselves in certain ways doesn’t mean they should lose autonomy in other ways, such as making decisions for themselves. It’s actually crucial that they don’t. Caring for aging parents and grandparents is sometimes blithely compared to caring for children. In both cases, we always think we have their best interest at heart. But old age is not childhood; it’s a totally distinct phase of life. With children, we aim to keep them safe at all costs. We act as though we know what’s best for them, because we do—or at least we can confidently pretend to. In caring for elders, their dignity and autonomy are paramount. The goal is to maximize quality time, striking a balance between prolonging life and making it comfortable and joyful. Striking the proper balance isn’t defined by some external standard; it’s defined by their own wishes. We non-elders are rarely positioned to deem those wishes valid or invalid. Even as bodies break down and memories start to fade, as long as people have the cognitive capacity to make decisions for themselves, our job as caregivers is to enable fulfillment of those wishes. [Read: The U.S. is repeating its deadliest pandemic mistake] But the crucial caveat is that this situation would change if your grandmother were refusing to wear a mask or attempting to do things that put other people in harm’s way. She shouldn’t be throwing dance parties. This sort of situation is where it could become morally defensible to step in—for an elder or for anyone else who’s doing things that put people at risk. Autonomy ends with recklessly endangering others. In terms of things like hair salons, this is where public-health policy can take a lot of burden off individuals. If establishments are to open, officials should require everyone involved to wear a mask. Building codes should ensure good ventilation. Still, for the foreseeable future, things like haircuts will never be perfectly safe. Getting a haircut isn’t even a zero-risk proposition in normal times, with someone looming over you with various sharp instruments. The pandemic should force us to pare down to only the things that are most beneficial and least risky to us. It’s going to last a long time, and we can’t give up absolutely everything. Overall it sounds like your grandma is being very careful. She is frail and sick and grieving, and wants to do one semi-risky thing that has a lot of value to her. If she’s doing it as safely as possible, you can disagree with her decision, but I wouldn’t refuse her autonomy. The experience of going to a salon has value beyond looking good—and even more so in this moment, when community and ritual are hard to come by. Wanting that glimpse of normalcy is not trivial or superficial or vain. For your grandma, this one may be worth it. But truly, it’s not up to me, and it’s not up to you. “Paging Dr. Hamblin” is for informational purposes only, does not constitute medical advice, and is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. By submitting a letter, you are agreeing to let The Atlantic use it—in part or in full—and we may edit it for length and/or clarity. from https://ift.tt/39BQLzv Check out http://natthash.tumblr.com This month, Berkeley public schools, like many school districts across the country, announced they will not start the year with full-time, in-person school. Soon after, J Li, a business-innovation strategist who lives in the area, noticed moms in the local Facebook groups turn, like starlings at dusk, to one topic in particular: homeschool pods. Reluctant to face more months supervising Zoom classes, wealthy parents are grouping together in families of three or four and hiring someone to privately teach their children, at a cost of thousands of dollars a month. “So what are poor parents going to do?” I asked Li. “I mean, get fucked,” she said, frustrated that the government hasn’t come up with a solution for everyone. As the first day of school rapidly approaches, people across the United States who can’t afford this system of private governesses are desperate for alternatives to in-person schooling or all-day Zoom. Both these options, after all, raise thorny objections. Teachers, and many parents, are reluctant to resume in-person schooling in the fall, fearful that children could contract the virus and spread it in their classrooms or at home. Meanwhile, virtual learning appears to be a giant failure. Not all students have internet access, so poor kids are falling behind. Even if they can get online, having a 7-year-old stare at a computer all day is generally not seen as advisable by child-development experts. Given this dearth of good options, the best one appears to be moving the classroom outside. A small group of activists across the country are pushing for schools to consider teaching children in person, but outdoors in a park or even a parking lot. Outdoor time has always been healthy for kids, but that’s especially the case now: One study found that the odds of catching the coronavirus are nearly 20 times higher indoors than outdoors. Though it isn’t free of problems, learning outside might be the only way to provide parents with a break, kids with an adequate education, and teachers with protection from the coronavirus. [Read: The school reopeners think America is forgetting about the kids] But while some schools are considering outdoor classes as at least a partial option for this fall, outdoor learning will likely be limited to tentative experiments in pockets of the country. More widespread adoption of outdoor learning has been stymied by a lack of funds, cautious local leaders, and logistical hurdles. The result is that millions of kids, even those living in temperate climates, will probably not be going to school this fall in what may be the safest way possible. It might sound crazy, but kids learn outside all the time, and did so even before the pandemic. About 250 “forest schools” exist in the U.S., in which younger kids spend much of their time in nature, and some have stayed open during the pandemic. In Denmark and Italy, some schools have reopened in recent months because students are spending as much of their day outdoors as possible. Outdoor school has even been tried during past epidemics: In the early 1900s, during a tuberculosis outbreak in Rhode Island, kids attended a school with the windows always open, even in the winter. They sat in sleeping-bag-like blankets and had heated soapstones placed at their feet, The New York Times reported. Eventually, there were 65 such “open air” schools around the country. And many places in less-developed countries have rudimentary classrooms that are functionally outdoors. “There are people in countries throughout the world who learn outdoors every day,” said Scott Goldstein, the director of EmpowerEd, a teacher-advocacy organization that has been working on getting schools to hold classes outside. “They use good, old-fashioned chalkboards.” Sharon Danks, the CEO of Green Schoolyards America, an outdoor-education advocacy group, told me that representatives from about 25 different cities, schools, and districts have been in touch with the group and are considering outdoor schooling, though none have said yet that they will definitely do school all outdoors, all the time. Outdoor school would look like an extremely low-tech, mildly uncomfortable version of a regular school day, though perhaps with more sunscreen. Kids would be at a soccer field, in a park, or on another patch of green, advocates told me, or even in the middle of a closed road, if the school lacks green space. They’d sit under a tree or portable shade structure or simply wear sun hats. Some schools are hoping that events companies, which currently aren’t planning as many weddings or conferences, might lend them some tents. Teachers would probably retool their curriculum to be more nature-focused, and kids would get a break from the masks they’d be wearing indoors. Some of the logistical challenges to this vision are still being ironed out. The idea is that kids would wear jackets or head for the gym or cafeteria on rainy or cold days—and schools would transition to online learning in mid-November, before the weather turned truly frosty in much of the country. In Seattle, which is hoping to do outdoor learning for part of some younger kids’ school day this year, Liza Rankin, the school-board director of the city’s northernmost district, told me that they are “used to dealing with a little rain” but nevertheless hope to get some extra jackets donated. Outdoor schooling in August or September would be harder to pull off in hotter states, where even in the shade, temperatures can be too scorching to withstand for an entire school day. Perhaps the biggest hurdle is transportation, because even if kids are able to sit in a field all day, they still have to get there somehow. Some of the outdoor-ed advocates suggested staggered shifts of buses that would shuttle a smaller-than-normal number of kids. Nancy Striniste, the founder of EarlySpace, another outdoor-education advocacy group, suggested “biking buses” and “walking buses,” in which parents would walk or bike groups of kids to school, though of course not all students live near their school or have parents with the time to do this. “We’re working on,” the transportation issue, says Lisa Luceno, the senior director of early-childhood strategy at Briya Public Charter School in Washington, D.C., which plans to educate its 65 preschoolers outdoors for a few days a week this fall. [Read: I can’t keep doing this. Please open the schools.] Some of these challenges wouldn’t be impossible to overcome in temperate states such as California. In fact, if outdoor education does happen on a broad scale, it opens up the possibility that only the states with the best weather would be able to educate children in person year-round. This might give way to yet another coronavirus-induced educational disparity: between kids who live in blustery climates and kids who don’t. But it might not even come to that. Both the San Diego and Los Angeles school districts have already announced they will start school online in the fall. People who oversee large school districts—even in sunny areas—seemed unfamiliar with the concept of outdoor school when I asked about it. “There was no proposal for outdoor learning that I recall. It was not part of the conversation in board meetings,” Maureen Magee, the communications director for the San Diego Unified School District, told me. The same is true at a national level. When I asked Dan Domenech, the executive director of the School Superintendents Association, about outdoor education, he said, “I am not aware of any districts that are planning to do that.” Schools that do want to experiment with outdoor learning will have to first clear some bureaucratic obstacles. In some states, districts would have to apply for waivers to be exempt from local requirements to teach school online. Most public schools, which tend to be cash-strapped even in normal times, would need some kind of additional funding for equipment and staff, either from philanthropists or local families. Much like with other aspects of the pandemic, the federal government has been largely absent from this debate, leaving schools to figure out how to open without giving them the resources to do it safely. (A request for comment from the Department of Education went unanswered.) Schools might also need approval from their school board and from teachers’ unions, which still might not be comfortable with in-person instruction, even outdoors. In response to a request for comment on this issue, Randi Weingarten, the president of the American Federation of Teachers, said, “Using outdoor space to keep students safe and physically distant is one option in climates and on campuses that permit it, with educators who are trained and resourced to staff it, but it’s a Band-Aid solution to a much larger, long-term problem of how to safely and equitably get kids the education they need amidst a global pandemic.” Public and private schools also have differing degrees of autonomy. In many places, public schools would be able to teach outside only if the local school district allowed in-person learning—and so far, many are reluctant to do so. Most charter schools and private schools, meanwhile, could open up in-person instruction, both indoor and outdoor, without waiting on the district’s go-ahead. This reflects those schools’ greater resources and flexibility—and also explains why in some cities, public schools are staying closed while private schools just a few miles away are going forward with in-person instruction. But another explanation is that Americans are simply underestimating the harm to kids of spending even more time at home by themselves. In mid-July, the National Academies of Sciences, Engineering and Medicine warned against this route, issuing a report saying that school districts should “prioritize reopening schools full time, especially for grades K-5 and students with special needs.” I asked Vanessa Carter, an environmental-literacy content specialist with the San Francisco Unified School District, Why isn’t the movement broader? Why aren’t all elementary schools setting up tiny desks on their soccer field right now? “I ask myself that question every day,” she said. Carter has been working to bring outdoor learning to the district. “I think that many people can only be as imaginative as what they’re familiar with.” Most kids in the U.S. go to school inside, so when you hear the words return to school, you think return to the inside of a building. As a result, the richest kids have access to homeschool pods, but the solution that might work best for poorer ones is often dismissed as too difficult before it’s even tried. from https://ift.tt/30XqxmW Check out http://natthash.tumblr.com On this episode of the podcast Social Distance, Katherine Wells gets the results of her coronavirus and antibody tests. She has questions about what they mean, so an expert joins to explain the immune system (with help from James Hamblin’s metaphors). Lisa Butterfield is a tumor immunologist who works in cancer immunotherapy. She’s the Vice President of Research and Development at the Parker Institute for Cancer Immunotherapy and an adjunct professor at University of California, San Francisco. Listen to their conversation here: Subscribe to Social Distance on Apple Podcasts, Spotify, or another podcast platform to receive new episodes as soon as they’re published. What follows is an edited and condensed transcript of their conversation. Wells: Are you the type of scientist who always figured a pandemic was around the corner, or are you the type that really never thought it could get to this level? Butterfield: I’m not surprised, given the signals we’ve seen from around the globe where humans have increasingly encroached on natural areas and are exposed to more things that are able to jump species. I watch a lot of zombie movies, so I’m just relieved it’s not the zombie apocalypse yet. Hamblin: Some of the only exposure to the idea of what a pandemic could look like had come through movies like Contagion and Outbreak. Transitioning to immunology: COVID-19 can affect people in so many different ways because people’s immune responses vary in so many different ways. Butterfield: Absolutely. You and I could have five times different numbers of T cells—white blood cells in the circulation—and be perfectly healthy. There is enormous variation. Wells: Could you give me as simple as possible an explanation of how the immune system works? Hamblin: Can you explain ... the solar system? Butterfield: Yeah, the immune system is beautiful in its complexity and specificity. That makes it challenging to talk about in any detail. We also love our jargon in immunology. The immune system is there to protect us from infection and the things we encounter in the environment. There are cells and molecules in the blood that are ready to immediately react when they detect something. And then the more specific part of the immune system takes about a week to ramp up. So that’s why you might get sick first, but then you clear the infection. Hamblin: I’ve used this metaphor before that you have this innate immediate response, and it’s like the townsfolk grabbing their pitchforks and torches and immediately responding to this invasion. And then about a week later, you have the Navy SEALs, who were really efficient at fighting some invasion. They come later, but they hang out afterwards. Wells: The antibodies are the week-later response. Is that right? Butterfield: Yes. That’s the specific response of the Navy SEALs that shows up a week later when the immune system starts to see what’s going on. It harnesses two other parts of that specific immune system, the T cell and the B cell. The B cell makes the antibodies—and those are proteins floating around the blood, looking for that thing that they’re specific to. Our hope for the antibody part is that they’ll stick to the outside of the virus and block that part that interacts with the rest of the body that allows the infection to take place. And so we’ve got “neutralizing antibodies.” We neutralize the infection and the ability for the virus to get into any of the other cells in the body. Hamblin: That might sound like jargon to some people. It’s really important that everyone understands that you can have antibodies that bind to a virus that are not neutralizing and the virus is still able to bind to your body cells and do harm. And then you can have neutralizing antibodies like you’re discussing. And those are super effective. And that is our hope that that is what we are seeing in the antibody tests. There are diseases like HIV where you have antibodies, but you don’t clear the virus. If they are Navy SEALs, sometimes the virus just sort of has like bullet-proof armor ... I guess you could say it’s an invader like a zombie or something. And the Navy SEALs just cannot neutralize this thing. Butterfield: Yeah, they fire all their bullets and it keeps coming. Wells: I got an antibody test recently and it came back negative. Does that mean I don’t have the neutralizing antibodies? Butterfield: If the test was conducted properly, it answered the question it asked. And it may have asked the total antibodies: has your body’s seen this virus and had an antibody response of any kind? Or it could have specifically asked, if you saw the virus: did you come up with that really effective antibody response? Most of the tests I’m aware of ask the total antibody question. Hamblin: What’s your sense right now about how likely it is that those would be neutralizing antibodies? Butterfield: The data I’m aware of thus far says that if you have positive total antibodies, that some of those antibodies really will be the good neutralizing effective antibodies. Then the question is: how much? Are there enough of them? And are they going to hang around long enough to protect you? And that’s the next part of the mystery we have to solve. Wells: When do we think we could say: Okay, having antibodies at this level actually means you’re immune. Butterfield: Well, hospitals and universities and different companies are testing [for antibodies] all the time. And if our hope is that antibodies could protect you for a year, kind of like an influenza vaccine is thought to protect you for that year’s flu. From starting to collect the data, to having so much exposure opportunity that we think we have an answer. Wells: I’ve been reading about the idea that you lose these antibodies over time. What does that mean? Butterfield: The data showed that there is a decline in what was measured over time. And that’s normal to an extent. The immune system regulates itself. In an infection, you’ve got those early responders—the villagers with pitchforks trying to stop something initially. Then the Navy SEALs came in after a week and they really specifically targeted exactly what the problem was. And then the problem goes away, the infection goes away. The villagers already went back to their lives when the Navy SEALs showed up. And now the Navy SEALs go back to headquarters and wait for the next problem and the village goes back to normal life. You might leave a couple Navy SEALs there, just in case. Wells: What is the mystery of coronavirus to you, as someone who thinks about this all the time? Butterfield: The thing I worry about the most are long-term effects of the virus, which we’re just starting to see. I was hoping, like all of us were hoping, that it was going to be a bit more analogous to an upper respiratory tract infection, where it would stay in one place, do one thing, and be cleared. And that’s not how this is going. This is affecting a lot of different organ systems and it’s leaving people with residual effects even after they’ve gotten rid of all signs of the virus. Hamblin: So, in the metaphor, when you deploy the military into a small village to defend it, the deployment itself can create issues. It might be overall good. You want the Navy SEALs in there. But it’s obviously a very difficult thing to do. Butterfield: The Navy SEALs come in and some buildings get blown up, but the buildings can be rebuilt. Part of it is taking time to rebuild the buildings. You’ve got some tissue destruction and you can heal yourself. But then, years later, you realize that all the bombs and things made the ground toxic. Hamblin: You’ve created some zombies, possibly. Wells: Oh, my God, this is really scary. Just to clarify one thing about these tests: The test results for antibodies are not testing for T cells, which could actually have some Navy SEAL-like properties? Butterfield: Correct. First, we had to figure out how to identify the virus-specific T cell: which Navy SEAL was looking for the virus, and not looking for something else. We can now do that in a number of cases. Hamblin: That’s a bit of hope, right? People were seeing these antibodies waning and starting to panic. And what you’re saying is: that’s not the only part of the puzzle. There are other things that could help a person, even if antibodies win. Butterfield: Absolutely. That’s part of the excitement about some of these early data from the vaccines, because these vaccines are designed to both create antibodies and to activate killer T cells. That’s something we’ve learned along the way: how to activate both types of immune response at the same time, antibodies and T cells. I think we can do that with these vaccines. We don’t know how good or how effective yet, but it’s very encouraging they can do both. That’s going to be good and that’s going to stop some of the damage. So there won’t be all of those munitions poisoning the ground and all of the homes blown up. There’ll be a couple select homes that go because that’s where all the virus was and then maybe the Navy SEALs will leave earlier and we won’t have as much to rebuild. Hamblin: Just a few zombies wandering in and out occasionally. Butterfield: One or two, but, you know, they’re okay. Hamblin: Oh, that’s just Steve. He’s undead, but he’s no harm. Wells: I’m going to have the worst nightmare of my life tonight. from https://ift.tt/33d3nMv Check out http://natthash.tumblr.com Editor’s Note: The Atlantic is making vital coverage of the coronavirus available to all readers. Find the collection here. Nearly five months into the pandemic, all hopes of extinguishing COVID-19 are riding on a still-hypothetical vaccine. And so a refrain has caught on: We might have to stay home—until we have a vaccine. Close schools—until we have a vaccine. Wear masks—but only until we have a vaccine. During these months of misery, this mantra has offered a small glimmer of hope. Normal life is on the other side, and we just have to wait—until we have a vaccine. Feeding these hopes are the Trump administration’s exceedingly rosy projections of a vaccine as early as October, as well as the media’s blow-by-blow coverage of vaccine trials. Each week brings news of “early success,” “promising initial results,” and stocks rising because of “vaccine optimism.” But a COVID-19 vaccine is unlikely to meet all of these high expectations. The vaccine probably won’t make the disease disappear. It certainly will not immediately return life to normal. Biologically, a vaccine against the COVID-19 virus is unlikely to offer complete protection. Logistically, manufacturers will have to make hundreds of millions of doses while relying, perhaps, on technology never before used in vaccines and competing for basic supplies such as glass vials. Then the federal government will have to allocate doses, perhaps through a patchwork of state and local health departments with no existing infrastructure for vaccinating adults at scale. The Centers for Disease Control and Prevention, which has led vaccine distribution efforts in the past, has been strikingly absent in discussions so far—a worrying sign that the leadership failures that have characterized the American pandemic could also hamper this process. To complicate it all, 20 percent of Americans already say they will refuse to get a COVID-19 vaccine, and with another 31 percent unsure, reaching herd immunity could be that much more difficult. [Read: We don’t even have a COVID-19 vaccine, and yet the conspiracies are here] The good news, because it is worth saying, is that experts think there will be a COVID-19 vaccine. The virus that causes COVID-19 does not seem to be an outlier like HIV. Scientists have gone from discovery of the virus to more than 165 candidate vaccines in record time, with 27 vaccines already in human trials. Human trials consist of at least three phases: Phase 1 for safety, Phase 2 for efficacy and dosing, and Phase 3 for efficacy in a huge group of tens of thousands of people. At least six COVID-19 vaccines are in or about to enter Phase 3 trials, which will take several more months. We are almost five months into the pandemic and probably another five from a safe and effective vaccine—assuming the clinical trials work out perfectly. “Even when a vaccine is introduced,” says Jesse Goodman, the former chief scientist at the Food and Drug Administration, “I think we will have several months of significant infection or at least risk of infection to look forward to.” All of this means that we may have to endure more months under the threat of the coronavirus than we have already survived. Without the measures that have beat back the virus in much of Europe and Asia, there will continue to be more outbreaks, more school closings, more loneliness, more deaths ahead. A vaccine, when it is available, will only mark the beginning of a long, slow ramp down. And how long that ramp down takes will depend on the efficacy of a vaccine, the success in delivering hundreds of millions of doses, and the willingness of people to get it at all. It is awful to contemplate the suffering still ahead. It is easier to think about the promise of a vaccine. “There’s a lot of hope riding on these vaccines,” says Kanta Subbarao, the director of the World Health Organization’s flu collaborating center in Melbourne, who has also worked on other coronavirus vaccines. “Nobody wants to hear it’s not just right around the corner.” Vaccines are, in essence, a way to activate the immune system without disease. They can be made with weakened viruses, inactivated viruses, the proteins from a virus, a viral protein grafted onto an innocuous virus, or even just the mRNA that encodes a viral protein. Getting exposed to a vaccine is a bit like having survived the disease once, without the drawbacks. A lot remains unknown about the long-term immune response to COVID-19, but, as my colleague Derek Thompson has explained, there are good reasons to believe getting COVID-19 will protect against future infections in some way. Vaccine-induced immunity, though, tends to be weaker than immunity that arises after an infection. Vaccines are typically given as a shot straight into a muscle. Once your body recognizes the foreign invader, it mounts an immune response by, for example, producing long-lasting antibodies that circulate in the blood. But respiratory viruses don’t normally fling themselves into muscle. They infect respiratory systems, after all, and they usually sneak in through the mucous membranes of the nose and throat. Although vaccine shots induce antibodies in the blood, they don’t induce many in the mucous membranes, meaning they’re unlikely to prevent the virus from entering the body. But they could still protect tissues deeper in the body such as the lungs, thus keeping an infection from getting worse. “The primary benefit of vaccination will be to prevent severe disease,” says Subbarao. A COVID-19 vaccine is unlikely to achieve what scientists call “sterilizing immunity,” which prevents disease altogether. One way to boost the effectiveness of a respiratory-virus vaccine is to mimic a natural infection, by spraying live but weakened virus into the nose. FluMist, for example, contains weakened flu viruses, and a handful of research groups are looking into the strategy for COVID-19. But live virus vaccines are riskier because, well, the virus is live. “We don’t want to be spraying coronavirus up people’s noses until [we] are absolutely sure that it’s actually a virus that can’t spread from person to person and that it can’t make somebody sick,” says Kathleen Neuzil, the director of the University of Maryland’s Center for Vaccine Development and Global Health. “It will just take time.” With this first generation of vaccines, though, speed is of the essence. An initial vaccine might limit COVID-19’s severity without entirely stopping its spread. Think flu shot, rather than polio vaccine. The FDA’s guidelines for a COVID-19 vaccine recognize it may be far from 100 percent effective; to win approval, the agency says, a vaccine should prevent or reduce severe disease in at least 50 percent of people who get it. “That’s obviously not ideal,” says Walter Orenstein, a vaccine researcher at Emory University who previously worked as the director of the National Immunization Program. “But it’s better than zero percent.” In recent weeks, multiple vaccine groups have released promising data that show their candidates can induce antibodies that neutralize the coronavirus in lab tests. Their next challenges are about scale: testing the vaccine in a Phase 3 trial with tens of thousands of people to prove it prevents infection in the real world, and then, if it works, manufacturing hundreds of millions, even billions, of doses. This is why even a vaccine that has already been tested in small numbers of people is still many months away. Phase 3 trials are the largest and longest of the three phases—normally, they would take years, but they’re being compressed into months because of the pandemic. Still, vaccine makers need to enroll tens of thousands of people to confirm efficacy and to look for rare and long-term side effects. It will take time to recruit participants, time to wait for them to be naturally exposed to COVID-19, time for any long-term side effects to show up, and time to simply analyze all of the data. Perversely, the high and rising rates of COVID-19 in the United States do make it easier to test vaccine candidates here. Any given participant is more likely to get exposed to the virus at some point. “It’s not good news for our country in any way, shape, or form, but … it makes it possible to accumulate cases,” says Ruth Karron, the director of the Center for Immunization Research at Johns Hopkins University, who also served on the Data and Safety Monitoring Board for Moderna’s Phase 2 vaccine trial. Moderna, an American company, is conducting its Phase 3 trial in the U.S. A group based at the University of Oxford, which is collaborating with the British-Swiss biotech company AstraZeneca, is running trials in the U.K., Brazil, and South Africa—the latter two countries chosen specifically because of their high numbers of COVID-19 cases. In the U.S., the Trump administration’s Operation Warp Speed is helping several vaccine makers invest in manufacturing facilities while these trials are ongoing. This could reduce the lag time between the approval and the availability of a vaccine, since companies might otherwise wait for FDA approval before scaling up manufacturing. But making hundreds of millions of doses is still a considerable challenge, especially for a novel vaccine. The leading COVID-19 vaccine candidates rely on technology that’s never been used before in approved vaccines. Moderna’s vaccine, for example, is a piece of RNA that encodes a coronavirus protein. Oxford and AstraZeneca’s vaccine attaches a coronavirus protein to a chimpanzee adenovirus. Neither has been manufactured before on the necessary scale. Consider what happened in 2009, the most recent time the world mobilized to produce vaccines to stop a pandemic. The disease was H1N1, more commonly known as the “swine flu,” and vaccine makers had the much simpler task of subbing the H1N1 strain into the seasonal flu vaccine they make every year. Despite many, many years of experience in making flu vaccines, the manufacturers hit an unexpected snag. Most flu vaccines are made from viruses grown in chicken eggs, and for some reason, the H1N1 strain did not grow very well in the eggs at first. “The amounts produced from a given amount of eggs were much lower than normal,” says Goodman, who led the FDA’s pandemic response in 2009. “So that really delayed things.” Then, once millions of doses were in the works, Goodman says, there weren’t enough facilities that could package the bulk vaccine into individual vials. The Department of Health and Human Services created a network of fill-and-finish facilities to address this problem in the future. Right now, Operation Warp Speed is also awarding contracts to make the millions of syringes and glass vials needed to package a COVID-19 vaccine. Without careful planning on these fronts, the U.S. could run into a demoralizing scenario where vaccines are available, but there is no way to physically get them to people. Even if all of this goes well—the earliest candidates are effective, the trials conclude quickly, the technology works—another huge task lies ahead: When vaccines are approved, 300 million doses will not be available all at once, and a system is needed to distribute limited supplies to the public. This is exactly the sort of challenge that the U.S. government has proved unprepared for in this pandemic. In the H1N1 pandemic, the U.S. government purchased the vaccines and allocated doses to state and local health departments, which in turn vaccinated people through mass clinics as well as employers, schools, hospitals, pharmacies, and doctor’s offices. Nationwide, the program eventually vaccinated about a quarter of all Americans—demand fell because the pandemic itself peaked not long after the vaccine became available. The 2009 vaccination program was built on the infrastructure of the Vaccines for Children Program, in which the CDC buys and distributes vaccines to states for children who usually are uninsured or on Medicaid. Immunization managers who work in these programs are well versed in the intricacies of vaccine storage and distribution, such as maintaining a cold chain for vaccines that could become ineffective at room temperature. But because they work with children’s vaccines, they deal mostly with pediatrician’s offices. “We didn’t have relationships with hospitals and internists and people who vaccinated adults,” says Kelly Moore, who was the director of the Tennessee Immunization Program in 2009. In August that year, two months before they got their first shipment of the vaccine, Moore’s team created a sign-up on the state immunization registry and sent out a newsletter every Friday with updates and training modules for handling vaccines. “Unfortunately,” says Moore, “that network has not been maintained because we haven’t had other vaccines to send them in 11 years.” Contact information is out of date. Rebuilding this network for adults will be even more important with COVID-19. Although the H1N1 vaccine was recommended for all ages, the focus was on kids, for whom the flu was particularly dangerous. The opposite is true of COVID-19, which is more of a threat to older adults. Some of the leading COVID-19 vaccine candidates could also pose new logistical challenges, if they require storage at temperatures as low as –80 degrees Celsius or multiple doses to be effective. In fact, a COVID-19 vaccine is quite likely to require two doses; the first primes the immune system, allowing the second to induce a stronger immune response. Officials would have to balance giving one dose to as many people as possible with giving a second dose to those who already had one. “That was a complication we didn’t face in 2009, and we were so grateful,” says Moore. Although the CDC took the lead in distributing H1N1 vaccines in 2009, Claire Hannan, the executive director of the Association of Immunization Managers, says the agency has been oddly silent about plans for a COVID-19 vaccine since April. “Initially, we were having planning calls with CDC right away,” she says. “And then nothing.” She has unsuccessfully tried to get in touch with Operation Warp Speed, which has suggested the Department of Defense may also get involved in vaccine distribution. “We continue to ask CDC these many, many questions. And they don’t know,” she says. The CDC’s Advisory Committee on Immunization Practices is also normally responsible for recommendations on how to prioritize vaccines. The committee, which is composed of outside experts, last met in late June, when they discussed prioritizing vaccines for health-care workers, the elderly, and those with underlying conditions. They also considered prioritizing vaccination by race, given the racial disparities in COVID-19 cases. But now the National Academy of Medicine is convening a panel on the same topic, which is again causing confusion about who is responsible for making these decisions. In 2009, Moore’s job was to put the CDC advisory committee’s recommendations into practice. Two or three times a week, she would get an email from the CDC’s vaccine distributor letting her know the number of doses available for her entire state. In practice, though, an initial shipment of vaccines might not be enough to cover everyone in even the highest priority group, such as health-care workers. It was up to people like Moore to decide which hospital got how many doses, with the promise of more on the way next week. Then individual hospitals administered the actual vaccines to their employees based on priority status. This system is meant to be flexible and responsive to local conditions, but it also means the availability of a vaccine might seem to vary from place to place. For example, Emily Brunson, an anthropologist at Texas State University who studies vaccines, says that in 2009 there were cases in which one district interpreted recommendations strictly, giving the vaccine only to high-priority groups, and a neighboring district offered it to anyone who wanted it. The decision to distribute the vaccine through employee health centers in New York, which happened to include several Wall Street firms, also caused a big backlash. “There are many ways that things can be misinterpreted,” Brunson says. And during an initial shortage, these decisions can feel unfair—especially given tensions seeded earlier in the pandemic when the rich and the famous were getting COVID-19 tests while ordinary people were being turned away at clinics. If the pandemic so far is any indication, a vaccination program is likely to take place against a backdrop of partisanship and misinformation. Already, conspiracy theories are spreading about a COVID-19 vaccine, some of them downright outlandish. But the emphasis on speed—as in “Operation Warp Speed”—has also created real worries about vaccines being rushed to market. At a congressional hearing with five vaccine makers on Tuesday, company officials had to repeatedly push back against the idea that the industry might cut corners for a COVID-19 vaccine. “We’re going to be in a situation where some people will be desperate to get the vaccine and some people will be afraid to get the vaccine. And there’ll be probably a lot of people in between who are a little bit of both or not sure,” says Michael Stoto, a public-health researcher at Georgetown University. A vaccine, especially a novel one that doesn’t offer complete protection against COVID-19, will require careful communication about risk. “The fact that we can’t get ourselves straight about wearing masks will make that harder,” he adds. Given the number of Americans who are currently unsure of or opposed to getting a COVID-19 vaccine, Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, has warned that even a vaccine might not get the country to herd immunity if too many people refuse it. [Read: A new understanding of herd immunity] For the Americans pinning their hopes on a vaccine, a botched rollout could feel like yet another example of failure in the time of COVID-19. That could have disastrous consequences that last well beyond the pandemic itself. Brunson worries that such a scenario could undermine trust in public-health expertise and in all vaccines. “Both of those would be disasters,” she says, “in addition to the COVID itself being a disaster.” It could mean, for example, further resurgences of vaccine-preventable diseases such as measles and an even bigger challenge when battling future pandemics. For all the uncertainties that remain ahead for a COVID-19 vaccine, several experts were willing to make one prediction. “I think the question that is easy to answer is, ‘Is this virus going to go away?’ And the answer to that is, ‘No,’” says Karron, the vaccine expert at Johns Hopkins. The virus is already too widespread. A vaccine could still mitigate severe cases; it could make COVID-19 easier to live with. The virus is likely here to stay, but eventually, the pandemic will end. from https://ift.tt/3jJ02ur Check out http://natthash.tumblr.com In a few days, 30 million Americans will lose the $600 boost in unemployment insurance they’ve depended on every week. What happens next? Annie Lowrey, staff writer and author of Give People Money, joins to explain. Listen here: Subscribe to Social Distance on Apple Podcasts, Spotify, or another podcast platform to receive new episodes as soon as they’re published. What follows is an edited and condensed transcript of their conversation. Katherine Wells: What is the fiscal cliff? Annie Lowrey: When Congress passed the CARES Act, it did two really important things with the unemployment-insurance system. This is mostly a state program. When you pay taxes through your employer, you pay a little unemployment insurance tax and that raises money which then goes into a pool. The state administers those funds. So, the states have latitude, though not endless latitude, to set the benefit amount and the number of weeks of unemployment that you can receive. Then there are also rules about who gets unemployment. With the CARES Act, Congress created a special way for gig workers and other workers who normally aren't covered by the unemployment insurance program to get UI. And then they also added a really large benefit. $600 a week for recipients. Which is a lot of money, especially when you add it in with the normal UI benefit that you'd also be getting. That $600 a week bump is going to expire [federally on July 31st, but in many states either July 25th or 26th]. 30 million people will take a huge pay cut and they will mostly drop down to just getting the state benefit amount. The $600 benefit meant that most people were actually making just as much money or even a little bit more than they were making at their job. Now they’ll go down to making, in some cases half as much as they were before. This is a catastrophe for families that are really going to struggle to put food on the table and to pay rent. It's also a really bad thing for the overall economy because all of that spending is just going to disappear. Wells: Let’s start with that $600 a week. How has it been working? Do you have an example of what kind of impact that was having? Lowrey: I talked to a ton of people for a story about this. One of the people I spoke with was Bridgit. She was a concert photographer and a nanny and both of those things are just gone, now. Absent the $600, she would be below the poverty line. She would be getting about $200 a week in UI and it would be really hard for her. She's been applying for tons of jobs and she said she's willing to take almost anything but people really aren't hiring. Wells: What has been the effect of all of these people getting that $600? If it goes away at the end of this week, what happens nationwide? Lowrey: Normally income measures, the earnings of all of the households in a given state or given area, are very, very tightly correlated with the unemployment rate because you don't make money if you're not out working, right? What Congress did was so big, the amount of money they pushed in was so great, that the rise in the unemployment rate—from roughly four percent to now roughly fifteen percent, nationally—did not result in income losses for almost all families. That's amazing. Wells: That's exactly what they intended to do, right? They were like, all of these jobs are disappearing and we need to make sure that people don't sink into poverty and insecurity. Lowrey: Exactly. Where you do see income losses, and this is important, is in people who weren't covered by that UI expansion. I don't want to make it seem like it was literally everybody, because it wasn't and it's still a pretty patchy program. A lot of people are still waiting on checks or they don't qualify. But as a general point, Congress actually replaced all of the income losses for people who were covered by this and they really broadly expanded the number of people who are covered. And now that's going away. Wells: What happens on Friday? James Hamblin: That's the cliff, Katherine. Lowrey: Yeah, so Congress made this whole thing temporary. They put an expiration date on it and that date is at the end of the week. Right now, even if Congress did pass something, the states would need to reprogram their systems to accommodate for that change. We're already past the point where the states have the capacity to do that. These state UI programs are really underfunded. It's not a centralized computer—these are really rickety systems and they're individually run by the states. So, this is going to go away. Congress has said, and this is Republicans and Democrats, that they don't want it to drop to zero, but they're fighting over how long to continue to benefit and how much to give. Republicans don't want to give the full $600. There's going to be huge differences in the macro-economic effect depending on what they decide to drop the benefit amount to and how long they take to decide. Hamblin: Do you think that the $600 has been enough to encourage people to stay at home? Or should it be a different amount? Lowrey: It seems to be true that the $600 has had that effect, anecdotally. But one thing that I heard from a lot of people was that they felt like they were getting really mixed messages from the government about how to handle their unemployment. Republicans have said that the economy needs to restart and people need to get back to work. But a lot of governors or mayors have said, no, no, no, you need to stay home. We still have this uncontained outbreak. We want you to be safe, stay at home. I think that's been really confusing for people. I know that there are people who are studying the public health dimensions of the economic response here because I think it's intuitive and I think in time we'll know whether the $600 let people stay at home in a way that helped suppress the virus. But we haven't had coherent national messaging over what people should do and why. I think that that's been really distressing for families. Hamblin: That sort of clarity is so important. You're going to have this amount for a given period and you can know that you're going be taken care of. When people are talking about these plans going forward, are they talking about anything longer term? Or are we going to keep doing these patchwork extensions? Lowrey: It seems like we're just going to keep doing patchwork extensions. But there are currently proposals that would just take this out of Congress's hands entirely. One proposal is to tie extra payments that come from the federal government during recessions to the unemployment rate. So, for as long as the unemployment rate is elevated in your area the payments would just come automatically. There's an economist named Claudia Sahm who has developed, I think, one of the best proposals for this. In her version, there would also be a trigger. As soon as the unemployment rate starts going up, even if it's not totally clear we're in a recession yet, the unemployment insurance system would just expand, these additional payments would come, and then they could taper down in a kind of slow, clear manner as the unemployment rate dropped. That's a completely sensible thing to do. There are also really great proposals to fix the administration of unemployment insurance by federalizing it and having the Department of Labor administer it. I think that's a great idea but nobody is really talking about it and Republicans, for all sorts of reasons, would be really opposed to it. We really don't provide people with certainty. One thing I found when I was reporting this piece was people were hoarding the money because they were so unsure of whether it was going to go away entirely. Because the job losses have been concentrated among low-wage Americans, we're talking about the basics. Rent and food and housing. This is preventing people from slipping into material poverty. Wells: What happens next week when these people are not able to make rent? What is it going to look like? Lowrey: It's going to be bad. We don't know how bad because we don't know how much they'll replace the $600 with and how fast it will happen. But I think you will see an effect on consumption of the basics really quickly: buying gas, buying groceries, paying the electric bill. A lot of places still have ordinances preventing evictions but those are expiring and, in some cases, they're not enforceable. A lot of places have pushed utility companies not to do shut-offs during this period but that's not everywhere and, in some cases, those aren't enforceable. I think you're going to see a lot of stories of people who end up sliding into destitution. Those are the stakes here. The scale of how much of that happens—the breadth and the depth of the misery—is up to Congress. Congress really buffered the country from a lot of the worst effects of the recession but we're really going to feel it like a recession if this $600 goes away and they don't send out additional economic impact payments or do more to rescue businesses. Wells: What is the right amount to give people? What do you think should happen to minimize the economic chaos moving forward? Lowrey: Insofar as there's any downside to the $600, it's that it's probably having some pretty minor effects in terms of discouraging people to go back to work who otherwise would. That's real but it's probably not a big deal right now. Other than that, it's just a cost. And it costs a lot but this is not the time to worry about that cost. I don't see any reason to cut the benefit amount. I really don't. I don't think there's any way they're going to expand the $600 payment, but I do hope that they keep on pushing a lot of money out because it's one of the only good things in the economy right now and it's really important that it continue. I think it is disgusting and really disheartening that Congress has known about this cliff for a long time and they've chosen to just drive off of it. from https://ift.tt/3jCbkQM Check out http://natthash.tumblr.com Editor’s Note: Every Wednesday, James Hamblin takes questions from readers about health-related curiosities, concerns, and obsessions. Have one? Email him at [email protected]. Dr. Hamblin, We have been told that washing our hands with soap and water for 20 seconds kills the virus, and that the virus doesn’t stay viable on surfaces for more than a couple of days. So why are we told that masks need to be washed with hot water? Isn’t simply not using a mask for several days before wearing it again sufficient for any virus to expire before reuse? These recommendations don’t seem to rationally fit together. Linda Wieland Ottawa, Canada There is no such thing as a perfect mask. Every type involves trade-offs. A loosely wrapped bandanna may be barely better than nothing. N-95s dig into your face and bruise you. Gas masks are clunky and scare your neighbors. Surgical masks come closest to perfect for this moment. They are feather-light, breathable, and electrostatically charged to catch viruses without blocking air. They seal tightly around your face, but not so tightly that they cause injuries when worn all day. In an ideal world—one where we didn’t have to worry about supply chains, waste, or cost—surgical masks would fall from the sky each morning and evaporate each evening. Wearing homemade face coverings, let alone having to wash them, would be an alien concept, as absurd as fashioning one’s own pacemaker from household items. But as 2020 has made emphatically clear, this is not an ideal world. Even inside hospitals in the United States, which spends twice as much as the average country in the Organization for Economic Development on health care, doctors and nurses who typically discard masks after a single use have been instructed by the FDA to take the risky step of rationing and reusing them. New guidelines are being invented for this moment, and they don’t necessarily make sense. A public information page maintained by Johns Hopkins University advises that surgical masks should be thrown away when they are “visibly soiled or damaged.” Of course, having dirt or syrup on your mask doesn’t necessarily mean it’s nonfunctional. Meanwhile, masks that look perfectly fine could harbor the virus. In normal times, the use of homemade masks is actively discouraged, because they can be contaminated, they encourage touching your face, and they don’t clearly protect people unless they are made well and worn assiduously. But since we clearly can’t count on government helicopters dropping surgical masks on us anytime soon, cloth face coverings are going to be with us for a while. So we’ve had to put our trust in clothing brands, Etsy sellers, or our own ability to create medical devices. And it’s becoming clear that not all of the end products we call “masks” are functionally the same. Those in popular use right now run the gamut from plausibly effective public-health intervention to theatrics, depending on what they’re made of and how they’re used and maintained. [Read: We’ll be wearing things on our faces for a long time] An interesting study of the effectiveness of cloth facial coverings appeared last month in a physics journal. Researchers at Florida Atlantic University compared what happened when coughs and sneezes were blasted into various materials. They found that most any half-hearted attempt at a mask can catch large viral droplets spewing forth from your mouth and nose—though the droplets will still fall onto nearby surfaces if the mask isn’t tight around your chin. But when it came to stopping airborne viruses from penetrating the mask, some materials were better than others. Bandannas and similarly thin cotton face coverings provided minimal blockage of the aerosolized particles that can shoot through the cloth in a “respiratory jet.” Such jets are created when you speak loudly or cough or sing, and the viral particles can hang in the air and conceivably fill a poorly ventilated room. The underlying takeaway from the study was that the density of fibers in the cloth makes a big difference in how many tiny droplets travel from your mouth into the air. Surgical masks can be thin because their fibers are arranged to filter out particles, but when it comes to cotton, creating density means layering. Short of running your own physics experiment, a fair rule of thumb is that the blocking power of a cloth mask can be approximated by how hot and suffocating it is. There’s a reason a bandanna is more pleasant to wear than a T-shirt folded over 12 times: The latter lets less air through. The problem is that the value proposition of layering starts to fall apart if a mask is so thick that it gets sweaty: Cotton and other materials can become less breathable when wet. Moisture from our breath can build on the inside, too, as we breathe harder to cool ourselves. And wetness aside, fabric masks lose value if they’re so thick that they become overly burdensome to wear and people take them off. Once you’ve calibrated your mask to balance safety and livability, then it’s time to worry about it falling apart. This brings us to washing. Any material degrades with washing, as the fibers grow slightly thinner and farther apart. Avoiding overwashing is especially relevant to masks, because the tightness and integrity of the fibers is essential to their function. [Read: Refusing to wear a mask is an empty act of defiance] So, in our ramshackle approach to self-masking, there is good reason to think outside the box. One of the things we could be using more to our advantage during this pandemic is time. The virus can hang around for a few days on some surfaces, but it lives longer on hard surfaces such as metal doorknobs than soft ones such as cardboard or cloth. If you waited a week to reuse a mask, I see no reason that you shouldn’t feel certain it was free of the virus. Bacteria and fungi can grow on all sorts of mediums, but viruses need a host. Without one, their days are numbered. Light is also our friend. The Centers for Disease Control and Prevention recommends washing your mask like you would any other piece of laundry, by machine or hand, and then leaving it to dry in direct sunlight. This latter part may deserve more emphasis than the former. Intense UV rays can kill the virus in less than an hour. This doesn’t mean you’re safe from infection simply because you’re outside, but it does mean that surfaces and materials exposed to direct sunlight will carry the virus for less time than they would in the dark. Sunlight is a tool worth keeping in mind for specific uses like disinfecting makeshift masks, even if it can’t be inserted into people, as President Donald Trump has suggested. In sum, this may be the surest way to get the safest, longest life out of your mask: Have several masks, made to fit well around your nose and mouth. Make them as heavily layered as you can tolerate. After wearing them for a day or so, or in a high-contact scenario, let them sit for a few days in a sunny, out-of-the-way place. Between the effects of time and light, there should be little need for running a washing machine or going through the hassle of hand-washing your masks. Well, unless they just smell terrible. In that case, maybe it’s your teeth that need cleaning. If it sounds like I’m making this up based on best guesses, I am. Everyone is. We would ideally all be wearing surgical masks, and disposing of them frequently, but we didn’t prepare accordingly. So for all their flaws, cloth masks are important: Making them effective enough for use in daily pandemic life means we’re freeing up medical-grade masks for people who really need them, especially in places where they are still in short supply, such as the United States. Health-care workers around the world still need proper personal protective equipment more than a random guy named Gene who wants to go to the store to buy snacks. Supply chains and stockpiles could one day be made robust enough that everyone has ready access to surgical masks, for a low cost if any. No one would need to waste a thought on tearing up an old T-shirt and putting it against their mouth and nose in hopes that it will save their life and the lives of everyone around them. Americans were warned for years about the shortage of surgical masks, and the federal government ignored those warnings. The Trump administration continues to draw focus away from masks; the president until recently declined to emphasize the importance of wearing one. In January, I wrote “We Don’t Have Enough Masks.” We didn’t then, and still don’t now. “Paging Dr. Hamblin” is for informational purposes only, does not constitute medical advice, and is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. By submitting a letter, you are agreeing to let The Atlantic use it—in part or in full—and we may edit it for length and/or clarity. from https://ift.tt/2WIvz5t Check out http://natthash.tumblr.com In the face of unprecedented disaster, even elaborate safety measures can seem absurd and insufficient. For instance, to clear radioactive debris from the roof of the molten Chernobyl nuclear reactor, Soviet authorities resorted to using what they called “bio-robots.” About 4,000 human men were handed gas masks, gloves, and lead-lined boots and instructed to fling the radioactive graphite over the roof’s edge. To keep their radiation exposure relatively low, each worker would spend only a few minutes shoveling. Then the next bio-robot would take his place. I was reminded of the Chernobyl cleanup crew’s intricate safety dance when I was on the phone with someone in a typically much tamer profession: government contracting. The contractor in question—who asked to go by James, his middle name, to avoid professional repercussions—had been working from home in Ohio since the state’s stay-at-home order went into effect in mid-March. But the order was lifted in May, and on June 22, James says, his whole office was asked to return, even though coronavirus cases were rising worryingly in the state. Like the bio-robots, James and his co-workers are supposed to follow rules to minimize their risk in this obviously risky situation. At the beginning of the day, everyone gets their temperature taken. They are supposed to use hand sanitizer frequently and wear masks in common areas, such as the conference room and the kitchen. But James told me that almost no one wears masks in the conference rooms, and some people leave their nose uncovered as they mosey about the office. [Juliette Kayyem: Never go back to the office] James hasn’t asked his bosses if he can work from home, because, as a new employee, he’s worried about seeming like a squeaky wheel. But the risk of getting a disease with no cure has raised James’s anxiety levels, causing him to spend much of the day wondering whether the person across from him has the coronavirus, or whether the office’s air-conditioning is silently shooting infectious droplets his way. Thus tensed up through the workday, he has found himself acting out of character, cracking down on his co-workers like the COVID-19 police. When he recently saw a co-worker walking out of the bathroom without washing his hands, James barked at him that he was being disgusting. “That’s not something I would have done pre-pandemic,” he told me. “But I think I just kind of snapped in the moment, as I was standing there singing ‘Happy Birthday.’” Millions of Americans who normally work in an office are still working from home, their bosses unwilling to risk infecting them for the sake of butt-in-chair time. But others are not so lucky. Some workers are being called back in, even though the coronavirus is still spreading, and even if their job can be performed from home. Those people are stuck between the danger of exposing themselves to the coronavirus and the danger of losing their job during the worst recession in living memory. Some of them seek work elsewhere when the stress becomes too much to bear. [Read: How the coronavirus could create a new working class] The uneasiness about whether it’s safe to return to work is in part driven by President Trump’s largely deferring to states and localities when it comes to reopening. Several states reopened too quickly, and now face rising coronavirus infections and deaths. But if a state is technically “open,” there’s little to stop a business owner from calling workers back to their cubicle. Alison Green, the HR expert who gives advice at Ask A Manager, recently doled out tips for workers being asked to return to the office unnecessarily: “Point out that your competitors aren’t. Ask [your bosses] about how they’re planning for people who must take public transportation. Ask how they’re complying with every CDC recommendation listed here. Think about how you can generate some bad PR for them without risking your jobs.” She noted that if you are at high risk of serious complications from COVID-19, you can request remote work as an accommodation under the Americans with Disabilities Act. But not every situation is covered by the ADA, and not every person who is worried about getting sick is high risk. Even workers who are at high risk have found themselves without an easy way out. Dennis Cote, a barista at the Stumptown coffee shop in Portland, Oregon’s airport, received a voicemail from his manager in early July, a transcript of which he shared with The Atlantic. In the voicemail, the manager asked whether Cote was “ready to come back to work.” She appeared to suggest that if he wasn’t, she’d note his refusal in a “log,” which Cote feared would jeopardize his unemployment benefits. Cote was worried about returning, because he’s immunocompromised. “I have a lot of anxiety and dread about it,” he told me. Still, he planned to return, “because I’d rather be making some money than no money.” (LaTrelle’s Management Corporation, which operates that Stumptown location, said in an email, “We report job offers that are made, as we are requested to do so by the state.”) For other workers, the job isn’t worth the risk. I spoke with one woman on the condition of anonymity, because she doesn’t want to get fired from the real-estate firm in New York that she’s thinking about quitting anyway. A few weeks ago, she said, her bosses insisted she return to the office so she could, in their words, “integrate” and “make sure things are running smoothly.” The woman began having anxiety dreams about catching COVID-19. [Read: The U.S. is repeating its deadliest pandemic mistake] At first, she begged off by telling her managers that she was staying in the suburbs, too far from the city to commute every day. But soon, she plans to return to the city and simply not tell her bosses that she’s back. “I guess I have to not tell people where I am or where I’m living,” she mused. “I don’t want to be going into an indoor space right now with other people.” The woman told me she’s interviewing for other jobs—ones in which she can work fully remotely for the time being. That might become a more common choice for people who have other options. Even before the pandemic, remote work was an attractive perk that drew people to certain companies; people love their pajamas, even when their life isn’t on the line. As employers consider asking their workers to take health risks for their jobs, giving employees a choice in the matter might be wise. Even the Soviet bio-robots were given a choice—at least nominally—about whether to carry out their work. As Adam Higginbotham writes in Midnight in Chernobyl, before the men set off on their treacherous task, Nikolai Tarakanov, the deputy commander of the U.S.S.R.’s Civil Defense Forces, told them, “I’m asking any one of you who doesn’t feel up to it or feels sick to leave the team!” Of course, it’s debatable whether a major general of a totalitarian state’s army would really have taken “no” for an answer. But he did ask. Many American workers, meanwhile, don’t feel up to it. They don’t want to risk it all by hurling contaminated graphite off the roof, even if they’re equipped and trained. That’s especially true if they could be doing the same work from the safety of their couch. As the pandemic rages with no end in sight, more reluctant bio-robots might decide to turn in their lead boots and climb down. from https://ift.tt/30EFV7A Check out http://natthash.tumblr.com On this episode of the podcast Social Distance, the Atlantic staff writer James Hamblin talks about his new book, Clean: The New Science of Skin. Listen here: Subscribe to Social Distance on Apple Podcasts, Spotify, or another podcast platform to receive new episodes as soon as they’re published. What follows is an edited and condensed transcript of their conversation. Katherine Wells: What does it mean to be clean? James Hamblin: “Clean” started as a religious concept with a strong moral valence. It didn’t become associated with health and hygiene in any real sense until we learned about germ theory about 150 years ago. Since then, it’s been a slow growth of a lot of habits and practices that we sort of associate vaguely with health and hygiene and preventing infectious disease, but in many common uses today, it’s actually just a sort of a judgmental term that we use to say who is acceptable and who is not. Wells: What was the first recorded instance of the concept of cleanliness? Hamblin: Variations on cleanliness or purity were part of a lot of rituals. The Aztecs bathed people before killing them just to make sure that the person was pure. Baptisms and similar ceremonies are common in many religions. The point of this cleansing was never to remove microbes; there was no idea of what microbes were, and there wouldn’t be for a long time. Wells: What made you want to write a book about cleanliness, and why is it coming out during a time of extreme fear over germs? Hamblin: Well, I started working on this back in 2015 when there was some interesting new science coming out around the microbes that live on our skin. I wrote a story for The Atlantic that centered on a skin-probiotic company, for which I didn’t shower. I’d been leading up to it by minimizing my hygiene routine for a while, and for the story, I tried to see if I could just go with absolutely nothing. That got me into this idea of wondering why we do the things we do and how much of it is really associated with health. So I spent the last few years tracing those ideas and trying to break down the concept. I finished writing it at the end of last year and then this pandemic happened. Which, obviously, I did not anticipate. But I still think the book really holds up. Wells: What does it mean to be clean today? Are we too clean? Not clean enough? Hamblin: How would you describe “clean”? Wells: Germ-free, I think, is usually the way I think of it. Post-soap. Hamblin: It’s interesting that you think soap kills germs. Wells: Doesn’t it? Hamblin: No. Soap is a fatty acid that is combined with a base and heat and results in this product that you see as a bar of soap. It can become liquid depending on what kind of oils you use, but that’s all it is. Anything else that’s added to a soap makes it not a soap. For example, Dove is not a soap. It’s a beauty bar because there are emollients in it. Soap is just a collection of these molecules, called saponins, that will bind to an oil on one end and to water on the other. When you have, say, syrup on your hands and it’s really sticky and it’s not coming off with just water, you use soap and it miraculously washes the syrup off. One end of that molecule binds to the sticky, fatty syrup and the other binds to the water, and it washes away. The idea that soap kills microbes on your hands is not accurate and potentially bad because the act of removing microbes from your hands comes from a combination of scrubbing water and soap. You know how people are asked to wash their hands for 20 seconds or to sing “Happy Birthday”? Wells: Yes. I’ve heard that you should sing “Happy Birthday” twice. Hamblin: Right. You wouldn’t have to do that if the soap was killing the virus like a hand sanitizer, which is killing microbes. The act of washing hands is really about scrubbing—that mechanical force of removing whatever is on your hands. Wells: I thought the soap disintegrated the coronavirus cell walls? Hamblin: It can, because the cell walls have some fats in them, but that is not the primary action. It’s really about scrubbing and about washing everything off that whole layer of skin. Wells: Would you get the same result without soap? Hamblin: It would be much, much better to wash your hands without soap than to not wash them at all. If you just cover your hands in soap and then hold them under water for a moment, it’s not effective. A good example is toothpaste: You’ve probably brushed your teeth without toothpaste, right? Wells: I have. Yeah. Hamblin: Doing that is certainly better than nothing. It doesn’t have that minty freshness, but that mint doesn’t mean your teeth are actually cleaner. Most of the work of tooth brushing is done by the mechanical force. Toothpaste will sort of help remove any really sticky stuff that’s clinging to your teeth, but the brushing is the thing. We should think of hand-washing the same way. Wells: We’re in a moment where we’re all staying inside as much as we can. We are all trying to avoid contact with surfaces and other people. We are probably more sterile than we would otherwise be. Is that a wholly good thing? Is there such a thing as too clean? Hamblin: It seems that there is such a thing as being too clean. All those microbes all over you are serving some purpose in shaping your immune system, especially when you’re young. We know that people who have diverse skin microbiomes, just like gut microbiomes, have lower incidences of skin conditions like acne, eczema, psoriasis. Wells: Those are autoimmune conditions. Hamblin: Yeah, exactly. The immune system flares up in those conditions. The microbes your body is exposed to shape your immune system. When you are exposed to certain things, your immune system learns that it doesn’t need to flare up and try to mobilize all these inflammatory molecules to deal with the exposure. This is a radical oversimplification, but if your body is not exposed to those things, it’s more likely to overreact. A good example is food allergies. There’s this thing called the hygiene hypothesis—it’s sometimes called the biodiversity hypothesis. The idea is that when you don’t have biodiversity in your environment and in your exposures as a youth, you are at higher risk of allergic and inflammatory conditions like food allergies or eczema. There’s a famous study in the New England Journal of Medicine that looks at Amish populations. Amish populations don’t have the same rates of allergic disorders as genetically similar populations that have embraced the indoor, urbanized lifestyles that you andl I have. Amish people spend a lot of time outdoors and also keep animals, often in places adjoining their houses. So they’re exposed to soil and to all different kinds of species. It is not an isolated, sterile lifestyle. Wells: So being too sterile makes your immune system paranoid—it overreacts to exposures that aren’t harmful? Hamblin: That’s the theory. It’s also the environments that we’ve created. If you live in New York and stop showering, it wouldn’t mean that you are really exposed to a healthy mix of microbes. Wells: You would need to go out and lick a field in which animals graze. Hamblin: [laughs] Well, it’s not that simple, because there are not a lot of undisturbed microbial environments where you can safely get these exposures. There’s a lot of pollution and actually harmful pathogens out there. Short of moving to a farm, there are some things that we know can help. There’s some evidence of a sibling effect, where people with more siblings have fewer of these allergic and inflammatory conditions. People with pets have fewer, too. You could eat foods that are higher in microbes. I wrote about this in The Atlantic—fresh produce is a natural probiotic. There are microbes inside of an apple that you’re getting exposed to that are not there once you’ve turned it into apple juice. All of these things together will help create a healthy biome and healthy immune system. Wells: The temptation I’m having here is to think, Well, I should go out and expose myself to a bunch of stuff to build up the immune system. But is it too late for me as an adult? Hamblin: It would be more difficult than if you were a child, but if you can get out in safe ways, you should. In normal times, being around other people and exposed to pets and the outdoors are the general patterns that keep the immune system healthy. Wells: You mentioned that most of this sort of training of the immune system happens in childhood. Right now, kids aren’t in school and they’re not seeing people. They’re not going out and about as much. What’s the consequence of that? Hamblin: I think it’s similar to the consequence of kids not being exposed socially to other people or not seeing the world as much. There are going to be longer-term consequences to that, which we don’t know how to predict yet. But we do know that kids end up more worldly and grounded and intelligent when they’ve had a broad array of experiences in childhood. I think we should think about their biomes and immune systems in the same way. I wish I could tell you how that will play out. I’m not suggesting that people give up any of the targeted practices that are being advised right now, but I think it can be overdone. Your idea of clean can’t mean totally isolated and totally sterile. You need a definition of clean that embraces complexity and plurality and diversity. That is when the term genuinely becomes synonymous with health. from https://ift.tt/2CZ7RLh Check out http://natthash.tumblr.com |
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