Incremental risk amid COVID-19 re-openings: What do we value most?

Julian (his real name) has been extremely careful for many months, working from home, foregoing seeing friends, and avoiding stores. But his new puppy Rufus requires “socialization,” so by his own admission, he is being less careful as he/the dog interact with humans and other canines.

In a completely anecdotal and unscientific manner (and in definitive contrast to the methodology of my training), I have been polling friends, family members, and colleagues about their activities during the current phase of the pandemic.  The unrepresentative sampling frame includes no individuals who believe that the coronavirus is hoax.  Nor do they subscribe to the “just a flu” notion.  Further, my survey is limited to a few regions of the U.S.  I am curious about how people parse decisions about risk based on their own values. I have learned that individuals construct a highly personal value system about risking exposure to the coronavirus; this is risk tolerance.

There are so many factors that go into how to assess the exposure risks we are willing to take for non-essential activities versus the rewards we might receive in exchange. The interplay of age, health status, local restrictions, and economics (livelihood, transportation needs) are only a part of the equation.

I continue to act as a resource for some about what they should or should not do to minimize risk.  Although I am following the science, the updates, and reviewing the emerging literature, the volume of data is overwhelming and — distressingly — seems to be changing almost daily.   Therefore, I usually refer questions to several high-level experts.   For practical advice, Dr. Erin Bromage, a professor of biology who studies animal immunology, is unparalleled in his concise, even-toned approach.  He ladles out the “how-to” with a keen understanding that folks are going to need to be out and about, and stratifies the risks in plain language.

I’m currently focusing on the additive nature of the small/moderate risks we take.  Even the activities with low risk of virus transmission, when combined, signify a greater risk — regardless of other factors.  I term this incremental risk.  No one states this idea more clearly than Dr. Bromage: “The more we move, and the more interactions we have, the greater the chance of infection.”

Many other experts have staged risk of exposure, based on science and common sense.   I really like the simple graphic from the Texas Medical Association.

For adults (excluding work-related activity), there are a series of decisions made each day about what optional activities are ok, safe, probably safe, a little risky, but worth it.  This is exhausting; many of us are suffering from decision fatigue.  The social isolation, deprivation, and overall pessimistic tone of our world may lead us to take chances in the interest of preserving mental health. So, there is risk-reward inherent in each decision.

It has become more and more clear that being outdoors is much safer than being indoors, due to the aerosolization of viral particles. What that means is, despite what you may hear from eager merchants or one’s own sense of complacency, going inside – whether it is a friend’s home or a store, is a whole lot riskier than walking in the park – yes, even with masks.

Think about the activities you engage in during the course of a week and do the calculus:

  • Do you hug your kids who may have been out and about?
  • Do you allow others into your home (friends, cleaners, contractors, etc.)
  • Do you make many trips to stores?
  • Do you go to doctors (nonurgently), barbers, hair, or nail salons?
  • Do you share food with other people not in your household?
  • Do you dine in restaurants, indoors, or outdoors?
  • Do you go to gatherings of more than ten people?

And so on and so forth.

Each of these actions conveys a certain amount of risk, some more than others. If you did one of these, your risk would be lower than if you did all of these; and that is precisely my point.  It’s a matter of frequency. This might seem intuitive, but in the setting of economic and social pressure, combined with having to learn a whole new way of adaptive living, it may not be so self-evident, or you may justify the risk. Further, if you have gone to the store and feel safe, you may have created a false sense of security such that multiple trips do not seem to compute as increased risk.

Here’s what I”m hearing about:

Grocery shopping is not optional; it’s necessary.  But if you go every day and to multiple stores, you are increasing the chance you will be exposed. From my informal survey, this practice is extremely common.  Yet, experts advise to consolidate shopping.  In fact, in my experience, there is always at least one person (shoppers AND workers) in every store I have visited who is either not masked or masked incorrectly.

Many people report that they are going stir-crazy without seeing friends and family members or being among others. So the trade-off is clear:  maintaining sanity is prioritized.

Everyone wants things to return to normal, so they are doing normal things, albeit with precautions.  In reality, there is still so much that is unknown about coronavirus transmission, so it is too soon to attempt “normalcy.”

I offer my recommendations for decreased risk of acquiring COVID-19:

  • Use the Texas Medical Association graphic (link above) to perform a self-assessment of exposure risk.
  • Evaluate your choices on a continual basis to check in with potential for denial or justification of actions.
  • Look for hidden sources of transmission (e.g., repeated trips to the grocery or other stores).
  • Plan activities in advance to increase efficiency and prevent extra actions or surprises.
  • Consider telehealth visits in lieu of in-person doctor visits.
  • To the extent it’s possible, move activities to the outdoors.
  • Delay salon visits. (It’s a 7 out of 10 on the risk scale!)

Personally, I’m walking on the side of caution, but I understand how others might take a different approach. When I’m asked for advice about what is safe versus not, I emphasize only that it is key to be realistic – the opposite of being in denial – about the risks we subject ourselves to.  Importantly, this denial may be unconscious.

I take my cues from Dr. Bromage.  When he “tells” me it’s ideal to bring one’s own food and utensils to a friend’s backyard barbeque, that is advice I can easily follow.   Is this extreme?  No doubt, but it aligns with my own preferences, priorities, and values and harms no one.

Sara L. Merwin is the co-author of The Informed Patient: A Complete Guide to a Hospital Stay.

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