Build Your Holiday Bubble

 

This week, we seem to be stranded in COVID-19 purgatory. In the Houston region, new community cases are slowly inching up, as are new hospitalizations. The trend is concerning enough that most TMC hospitals are dusting off their surge plans in the event our health system is once again stressed. We still do not know if we are in the early phase of another exponential growth cycle, or at a precarious equilibrium. Based on recent stressors in our community, I fear it is the former. Public schools reopened for face-to-face instruction this week in Houston and other areas, the shorter days are driving people indoors and many are experiencing mask fatigue. In addition, much of Europe is experiencing a surge rivaling the first one, and reinstituting lock-downs. Much of the US, particularly in cooler regions, is also surging. I think we must assume we are in the early phase of another regional battle with SARS-CoV-2.

I know this is demoralizing for many, especially as we approach the holiday season. Many have given up so much already. Our lives have been disrupted by the pandemic in ways large and small. Should we sacrifice time with family and close friends over the holidays as well?

For a little ray of hope, I look to the recent NBA season. The NBA created a “bubble” in Orlando, played all their games, and completed their post-season. Lots of comingling of people, plenty of close, mask-less physical contact. How many infections since the NBA resumed regular season play in August? Zero. None of us have the resources of the NBA, and we cannot replicate their bubble (they tested everyone daily and took over entire luxury hotels). However, I believe it is possible to create your own “holiday bubble” and have a relatively safe and responsible time with family. Following the lesson of the NBA, forming an effective bubble requires planning, commitment and attention to detail.

Before we dive into the details, I need to start with a couple of significant disclaimers.

First, you need to honestly assess your own risk tolerance. The only way to remain completely safe is to remain maximally isolated. If you are elderly, immunosuppressed or have a serious underlying medical condition, you need to weigh the risks of holiday celebrations against the potential benefits. Creating a holiday bubble will help to minimize those risks, but cannot eliminate them.

Second, creating a holiday bubble is possible, but it will not occur without real commitment of all participants. One weak link will breach your bubble. Half-hearted commitments will only lead to a dangerous false sense of security. If everyone is not committed, you are probably better off celebrating exclusively with members of your usual household, and not mixing with family and friends from down the street, or across the country.

With those disclaimers in mind, here is my suggested process to create your own holiday bubble. It has specific tasks that must be performed on schedule. Count backward from the day your family plans on entering your holiday bubble to establish your timeline.

Today

• Get your flu shot. This will decrease the likelihood of developing a flu-related illness around holiday time, which could disrupt your plans.
• Have a serious family conversation. Do we want to commit? Are we willing to create and maintain a safe environment? DO NOT SKIP THIS STEP. Obtaining real commitment to form your bubble is the single most important part of this process:
• Who is at high medical risk in our family? What is our risk tolerance for exposing them in a family get-together? If your risk tolerance is low, even a bubble may be too risky for you.
• Are we committed to doing the substantial work necessary to create a “holiday family bubble?”
• There is variability in how seriously people are taking precautions. Beginning two weeks before you come together, is everyone willing to rigorously adopt good viral control practices? (mask, physically distance, avoid crowds). Your bubble will only maintain its integrity if everyone is fully committed. If you have a family member that cannot commit, they cannot be safely invited to your holiday bubble.
• Have everyone print the Holiday Bubble Checklist. Or, view a Spanish version. 
• Assign a Family Bubble Commissioner, a single individual who will take responsibility for reminding bubble participants of key milestones and encouraging compliance.
• Sign a family pledge. I know this may seem a bit overboard to some, but obtaining commitment is critical.
• Agree on a location. One of the best options is a private home where everyone will come and stay. It would be ideal if the location included some outdoor space, weather permitting. Keep in mind, this will be your bubble. Once everyone arrives, you are there to stay. No excursions, no visitors. Once in the bubble, you stay in the bubble.
• If flying, order face shields or goggles to protect your eyes, which are a potential portal of entry for the virus. Consider trying to obtain N95 facemasks. Cloth masks used in combination with eye protection afford an acceptable level of safety, equivalent to the protective equipment used by health care workers during routine hospital care. An N95 combined with a face shield or goggles would provide maximal protection, and is equivalent to the equipment used by health care workers when dealing directly with known or suspected COVID-19 patients. Regarding eye protection, either a plastic face shield or eye goggles are effective. Goggles must fit snugly. Air purification in many planes is excellent, but varies based on the airline and model of aircraft.
• If flying, take a direct flight if possible.
• Check any travel restrictions for the state that you will be visiting. Note many states have restrictions and quarantine requirements. Some international destinations have testing requirements. Remember to check the regulations for the state to which you are returning after the holiday as well.

Two weeks (14 days) prior to holiday:

• Everyone planning to enter the holiday bubble must make extra effort to limit contact with other individuals to reduce risk of exposure.
• If your job duties permit, work from home. Self-quarantine. Important: Quarantine is more than being cautious. It means staying home and avoiding all contact with anyone outside your regular household, even if masked.
• If self-quarantine is not possible, maintain scrupulous attention to distancing and cloth masking along with hand washing/sanitizing.
• Add a plastic face-shield or goggles to your cloth mask when you are indoors and in contact with others. Note, the face shield is in addition to, not in the place of a cloth mask.
• Daily symptom and temperature monitoring. If you become symptomatic or have any fever (even low-grade), seek evaluation by a physician and tested with a PCR test (for this purpose, avoid rapid tests). If your test is positive, cancel your participation in the bubble, along with all others who live in your household.
• Decide who will be cooking during the holiday. Stock up on non-perishable food items in advance.

5-7 days prior to holiday:

• Get a diagnostic test (PCR, not a rapid test). If positive, cancel your participation in the bubble, along with all others who live in your household.
• Stock up on hand sanitizer and disinfectant wipes for travel.
• Complete your food shopping. If you plan to drive, buy travel food in advance. Purchase perishable items for your holiday meal(s). Remember, you are quarantined. Use a grocery service with touchless delivery to maintain your quarantine status.
• Recheck travel restrictions.

Traveling to the bubble:

• Drive if possible.
• Make the trip in a single day if you can do so safely.
• Bring your own travel snacks
• Limit time in -- or avoid altogether -- crowded roadside fast food restaurants, truck stops, etc. Mask and distance when out of the car. Consider adding a plastic face shield in addition to a cloth mask.
• If you must fly:
• Wear a cloth mask (or N95 for maximal protection) and a face shield or goggles. Remember, eye protection is in addition to your mask.
• While on the plane, leave your mask and face shield/goggles on as much as possible. Ideally, they should stay in place for the entire flight.
• Skip the snacks and drinks.
• Use the restroom prior to boarding.
• Limit fluid intake for 30 minutes prior to departure, and during relatively short flights (two hours and less).
• Avoid use of the airplane lavatory. If you must use the lavatory, keep your mask on, and wash your hands thoroughly.

During the holiday

• If you are confident everyone has followed the above guidance, you are relatively safe in your bubble. Continue to use common sense. Play games, eat, sing songs, throw the football. Enjoy fellowship with (bubble compliant) friends and family. After all your hard work, planning and preparation, you can relax and enjoy the holiday.
• For high-risk family members (elderly, immunosuppressed) it is probably prudent to continue to follow good masking, hand hygiene and distancing practices.

This is not easy, but what in this pandemic has been easy? Decide who is in your holiday bubble, and start the conversation today. If people are committed, begin the process as outlined above. Do not skip steps.

Let us try and spread this message. If most of us create a bubble, we can minimize the risk that the holidays will become a super-spreader event, and we can keep our loved ones safe.

Take the pledge. If you are on Twitter, post when you have committed to creating your bubble using #HolidayBubbleBCM. Encourage others to do the same.

I wish you all safe holiday season, and one filled with companionship and love.

 

(Note:  Between June 2020 through November 2021, I wrote weekly COVID-19 pandemic updates seen through the lens of a health sciences university.  My intent was to provide reliable information, acknowledge legitimate concerns, console, and encourage.  Each posting reflects issues our community was experiencing at that moment in time.  I have reproduced selected examples on this site).

 

 

Never Give Up, Never Surrender

 

Imagine a crisis in our community.  There is much about the crisis that makes it difficult.  The threat hangs over us continually; we can put it out of our minds temporarily, but it is always there in the background.  It strikes indiscriminately, causing death and disability to young and old alike.  Our best protection is defensive – everyone must modify their behavior to help keep all people safe.  As rigorously as we play defense, it does not eliminate the threat, and we yearn to go on offense.  We want an effective intervention that repels the invader, so we can return to our normal life.

SARS-CoV-2 and COVID-19?  As horrible as the global pandemic has been, and all the medical, social and economic turmoil it has wrought, I am describing the bombing of England during the Second World War.  From roughly June of 1940 to May of 1941, the English people endured a near continuous threat of death from the air.  In total, the nighttime bombings left 43,000 civilians dead, and more than three times that number wounded.  I just finished reading Erik Larson’s "The Splendid and the Vile," an excellent book that covers this period in history in a focused and engaging manner.  As I was reading, the parallels to our current crisis were unavoidable.

There are two major themes to the book.  First, in spite of the intermittent terror the population faced, life went on.  Weddings and baptisms; theater and music; the daily rhythms of work and school.  The English people endured incredible hardship, with no end in sight and the constant fear of invasion.  And life went on.

The second theme is the importance of leadership – specifically the role of Winston Churchill, who ascended to the office of prime minister during this most challenging time.

Churchill clearly had feet of clay: massive personal debt, probable over-indulgence in alcohol, odd personal boundaries (he was known to dictate correspondence to his secretary from the bathtub), quirky behaviors (he liked to wear a pink silk robe around 10 Downing Street) to name a few.  He was not perfect.

But he was a leader for that time.  He was masterful in his communication to the public: honest about the hardships faced and uncertainty of the situation, while maintaining a sense of unbridled optimism.  He dealt and managed in an environment of uncertainty (Will the U.S. enter the war? Will the Germans launch a land invasion?).  He assembled and maintained an effective leadership team.  He regularly visited sites of devastation.  He connected to, and wept with, the people.  He seemed to almost literally pick the nation up, and carry it through a horrific ordeal.

As I continue to monitor our COVID-19 metrics, and prepare to go to the polls to early vote, it is appropriate to pause and consider the importance of effective leadership.

The news out of Houston this week is a mixed bag. No one has a crystal ball, but on balance, I am discouraged by our numbers and believe we are on the cusp of another surge.  Although there is good news (the City’s test positivity rate is down to 5%), a number of our metrics are worsening.  From the TMC data, our R(t) value, after 32 days of staying below 1.0 (virus receding), snuck above 1.0 (virus is expanding).  New daily cases in the greater Houston area remain stubbornly in the 400-500 range, and the daily rate for the past three weeks is edging up (373, 394, 412).  New hospitalizations are increasing, albeit at a slow rate (0.9% daily increase) and the total census of COVID-19 patients in TMC facilities is again rising (1.3% daily).  Data from the Baylor diagnostic labs show the positivity rate increasing, along with the average viral load of specimens, a sign that the tested individuals may be more infectious.  There is increasing evidence that young adults (20s and 30s) are responsible for much of the spread.

I am afraid we will see the viral resurgence in the coming weeks, as are many regions across the world.  I hope I am wrong.  I hope the surge does not come, and if it does, that it is not as severe as we saw in July.  Let us all do what is within our power. Continue to beat the drum: mask/distance/avoid crowds.

As we prepare for a potential resurgence, and reflect on the role of leadership in crisis, I want to try to channel some of Churchill’s clear-eyed, realistic optimism.  I want us to come together, not be torn apart.  To that end, I have three specific requests of you today.

• Vote.  Do not wait until the last minute, do it this week.  Democrats and Republicans; liberals, conservatives and libertarians; supporters of “big oil” and the Green New Deal.  “MAGA-fanatics” and “Never-Trumpers.”  Vote.  We are living in divisive and turbulent times, but the nation has seen and endured worse.  Over time – if you participate – our system will work.
• Reach out to your Churchill.  We have all suffered through the pandemic, some far more than others.  I imagine everyone at some point has experienced a degree of anxiety and uncertainty; some have felt real despair.  Stop and reflect for a moment on who has helped you through this difficult time.  It may be a co-worker, supervisor, faith-leader, family matriarch/patriarch, teacher or civic leader.  Focus especially on those who are quietly leading out of the public eye – those who lead but do not get recognition.
  
  Now recognize your Churchill.  Right now, sit down and write them an e-mail.  Tell them how important they have been in helping you through this difficult time.  Tell them how they helped you.  Better yet, write them an actual letter.
• Start a global pandemic of support.  We are battling the “R(t)” and the pernicious nature of exponential viral spread: one infects two, two infect four, four infect eight, etc.  
  
  Let us try to create exponential growth in support of each other.  Share this message with two other people and ask that they send a note of thanks to their Churchill: the person that has helped them most through this time.  Then ask that they encourage two others to do the same.  Not as a social media campaign, not as a meme, not as a hashtag. Privately, individually, sincerely.

At the risk of beating this theme to death, I will finish with Churchill:

“We shall not fail or falter; we shall not weaken or tire.  Neither the sudden shock of battle, nor the long-drawn trials of vigilance and exertion will wear us down.”
 
Stay well (and vote!)
 

(Note:  Between June 2020 through November 2021, I wrote weekly COVID-19 pandemic updates seen through the lens of a health sciences university.  My intent was to provide reliable information, acknowledge legitimate concerns, console, and encourage.  Each posting reflects issues our community was experiencing at that moment in time.  I have reproduced selected examples on this site).

 

 

 

Bears and Bulls and Bars

 

It is never a good sign when I am writing my Wednesday message on Thursday morning. My intent this week was to write about bar openings. However, events have evolved so quickly, two versions of this message are already obsolete. Instead of rehashing the recent news, I will refer you to a couple of sources if you want to dig deeper into the issue.

I am going to focus on broader questions: Is it time to reopen bars in Harris County? (No); What role should personal responsibility play in community control of the virus? (A critical one); How are we doing in our efforts to have a civil, respectful public debate? (C+, but I tend to be an easy grader).

First, a couple of references for background reading. There is an article in this morning’s Houston Chronicle that does an excellent job summarizing the issues around bar reopenings. I would recommend reading this if you were under the mistaken impression bars were already open.

If you are interested in this topic, I would also encourage you to read Gov. Greg Abbott’s actual executive order (GA-32).  It is a detailed document, which makes attempts at a degree of nuance. For example, when drinking in a bar you must remain seated. That is, unless it is a wine tasting, in which case you may stand “if in a group of six people or fewer and there is at least six feet of social distancing or engineering controls, such as partitions, between groups.”

At a very high level (please read it for yourself) the Governor’s order a) permits bars to open at 50% of total listed capacity, b) but only in counties that do not have an excessive burden of COVID-19 in hospitals and c) in a major digression from prior executive orders, requires the county judge to opt-in to the reopening decision.

So should we reopen bars? First of all, let us acknowledge at this point in the debate, most of us are either viral bulls or bears. The primary concern of the bulls is economic. Government mandated limitations on businesses create hardship and long-term damage to the social, economic, emotional and medical well-being of people. Others are viral bears. Failure to adequately mitigate the virus in communities via public health measures, including limitations on businesses, will result in preventable death and a repetitive cycle of shut downs, reopenings and surges. There is validity to both positions. I work for an organization whose explicit mission is to improve healthcare. I acknowledge my bias – I am a bear, and suspect most, but by no means all of my colleagues, are similarly inclined.

Why is now not time to open our bars? Our numbers are stable to improving. Our R(t) has been less than one (indicating the virus is receding) for more than two weeks. Community cases (which we want below 200 per day) seem to have stabilized between 300-500. As I have previously reviewed, I have some apprehension this number is under-reported due to Texas DSHS data reporting challenges. New daily hospitalizations (probably a more reliable, but indirect estimate of disease prevalence in the community) are 20-25% of what they were during our July surge, but seem to be trending slowly upward over the past week. At best, our monitoring metrics are at a tenuous equilibrium. At worst, we are in the early phases of exponential growth. The unfortunate reality is we will only know which condition is true – best case or worst case – looking in the rear-view mirror.

Our numbers look relatively good, but the experience around the world should drive us to act cautiously. If we are too exuberant in our path back to normalcy, we will surge again. And shut down again. Critically, we are getting ready to stress our system further. School systems and parents still need to make decisions regarding a return to face-to-face instruction. Cooler weather will drive people indoors and will probably promote viral spread. Our equilibrium can only withstand so much perturbation – let us focus on getting children back in schools before we reopen bars.

A word in support of bar owners. Many are tax-paying small business owners, with personal investment in their enterprise. They employ Houstonians. They have families to feed. They are no longer receiving any government assistance to help mitigate the impact of government-ordered restrictions on their businesses. Their expenses continue, even though their revenue has evaporated. The rent still comes due. Those of us who had the good fortune to remain employed through this crisis should be careful not to vilify those who face a choice we have not had to make – close up shop, or find a way to do business in the challenging pandemic environment.

Gov. Abbott’s executive order creates some clarity, but in Harris County is likely to stoke political debate as to next steps. Should Judge Lina Hidalgo – clearly a “bear” – opt-in or opt-out? Most of us will have an opinion heavily influenced by our bullish or bearish inclinations. There will be passionate declarations made from both extremes. What can we all do to help drive a good outcome for our community? A few thoughts:

Proprietors of bars and restaurants:

• Demonstrate to those of us who are justifiably worried about the resurgence of this disease that you are taking it seriously. Most of the business community has, and we thank you. Some clearly have not.
• Look at your space. Create visual cues like floor markings and furniture placement to encourage distancing. Require masking upon entry. Creatively use outdoor spaces. Regularly walk the floor of your business, and critically assess if your patrons are effectively distanced. Do more than meet the technical requirements imposed by restrictions; meet their intent.
• Use the opportunity to innovate. Build your take-out business. Develop home mixed drink kits. Hold virtual on-line wine tastings, pre-selling the wine. I do not pretend to understand your business, or what is required to remain profitable, but I believe it is a risky strategy – from a business and public health perspective – to tie your economic recovery to packing people into a confined space.

Patrons and the general public:

• Reward those businesses – bars included – that are doing this well, and making a sincere effort to keep the community safe. Patronize them if they appear safe. Order take out. Tip generously. Tell your friends and colleagues when you have an enjoyable COVID-responsible experience.
• Remember, no matter how carefully crafted an executive order or local mandate might be, regulation will never be enough to ensure your safety. To repeat an analogy I used a couple of weeks ago: The government tells me how fast I am allowed to drive. I make a conscious decision to slow down when visibility is poor, because I have good situational awareness, and I am concerned about the safety of those around me. The same goes for viral safety. Stay alert and aware. If you walk into any environment and people are crowded and unmasked, turn around and walk out.

Americans/Texans/Houstonians:

• In what has become an increasingly divisive environment, let us all work to take the temperature down a notch or two. I freely acknowledge as a professional working in health care, I lean towards the “keep people safe and healthy, prevent the spread of the virus” side of the debate. I am a viral bear. I hope I have empathy for those who have experienced severe economic impact from the pandemic, who are justified in their desire to see things reopen as rapidly as possible. I hope I have respect for the informed opinions of bulls. There is a tension between these worldviews. In a democracy, that tension is a good thing – it helps drive better decision-making. It helps, that is, if we are actually listening to each other. Both sides – let us concentrate on listening more, and shouting less.

Stay well.

 

 

(Note:  Between June 2020 through November 2021, I wrote weekly COVID-19 pandemic updates seen through the lens of a health sciences university.  My intent was to provide reliable information, acknowledge legitimate concerns, console, and encourage.  Each posting reflects issues our community was experiencing at that moment in time.  I have reproduced selected examples on this site).