We're opening our state much too early, the doctors tell us.  But to no avail...

A Mother's Day Coronavirus outbreak is getting forecast here.  What a horrible thought! 

Perhaps a picnic instead of going out to eat this year.  Just a thought.

-Angela Valenzuela

“Doctors and Data” Suggest Greg Abbott May Be Reopening Texas Too Early

The plan deviates considerably from what many public health officials say is needed for Texans to reopen businesses.

BY

R.G. RATCLIFFE

DATE

APR 28, 2020

Governor Greg Abbott announces at an April 27 news conference that he would relax some restrictions imposed on businesses because of the COVID-19 pandemic.

In an upbeat news conference Monday, Governor Greg Abbott announced that all Texas restaurants, retail businesses, and movie theaters will be able to partially reopen for business by this weekend if they follow his guidelines. He insisted, as he’s done for weeks, that his reopening plan is based on “doctors and data,” and not the considerable political and business pressure that has been brought to bear upon him. The time has come to lift restrictions, the governor said, because “the COVID-19 infection rate has been on the decline over the past seventeen days.”

Abbott’s sunny assessment of the state of the pandemic, however, is at odds with the state’s COVID-19 data. According to the Texas Department of State Health Services website, there was a spike in reported infections on April 10, to 1,441 new cases, the most reported to date. On April 9, there were 877 new cases and on April 11 there were 890—and the number of new infections has held relatively steady ever since. On Friday there were 862 new reported cases. If Abbott had picked for his reference point any date other than the outlier of April 10, he could not plausibly state that the “infection rate has been on the decline.”

Despite the dearth of testing in Texas—which still ranks forty-sixth among the states in COVID testing per capita—reported cases are still rising in some communities. Collin County, north of Dallas, reported 30 new cases on Friday, up from 17 on Tuesday. Tarrant County, with Fort Worth at its center, saw a swing from 101 new cases reported on Wednesday to 150 on Thursday. The county health department lists the risk of community spread as “substantial.”

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The reopening plan also deviates considerably from what many public health officials say is needed for Texans to safely return to working in offices, shopping, and eating out. “The last thing we want is to waste all the great foresight and decisions we’ve made by ignoring the data and prematurely reopening wide,” William McKeon, president of the Texas Medical Center, told the Houston Chronicle. “It would be terrible for the community to respond so well, averting what happened in New York, and then find ourselves in a situation where we’re in our surge capacity and not able to offer citizens a bed, ventilator, and care they deserve.”

“As soon as we lift restrictions, whatever that strategy is, if it’s gradual or tiered or certain sectors of the economy or population are released first, we can certainly expect to see a spike in cases,” Rebecca Fischer, infectious disease epidemiologist at Texas A&M University School of Public Health, told the Texas Tribune. “What we want to make sure is that we’re far enough into the tail end of the epidemic that that bump will be minor and it won’t wind up shutting down the economy again.”

These experts, however, are not Abbott’s experts. His team of advisers includes a former state representative, Dr. John Zerwas, an anesthesiologist; Dr. John Hellerstedt, a pediatrician who has been an executive in the state health agency since 2000; and Mark McClellan, who served President George W. Bush as the Food and Drug Administration commissioner.

An Austin native, McClellan is a medical doctor, but is better known as a health policy and economics expert. He is a professor of business, medicine, and health policy at Duke University. He also is the son of former Republican state comptroller Carole Keeton Strayhorn. McClellan and some of his fellow researchers have been—to say the least—influential in guiding U.S. COVID-19 policy through two white papers. But even by McClellan’s standards, at least as they stood in these documents, Abbott is acting prematurely.

The first paper McClellan coauthored was published on March 19 and warned against taking the possibility of future infection spikes lightly. “With the isolation and other steps we are taking now, it’s possible that the epidemic spread of coronavirus will wane in the coming weeks and months. But it’s also possible that there will be additional waves of viral spread with the risk of another epidemic in the future.”

In the second paper, published by the American Enterprise Institute on March 28, McClellan and four coauthors outlined steps to reopening the economy. They outlined four prerequisites to moving beyond stringent social distancing. One that Texas apparently has met is having the hospital capacity to avoid “crisis standards of care.”

But there are serious questions about whether Texas has achieved the other three standards: the ability to test “all people” with COVID-19 symptoms; active monitoring of confirmed cases and their contacts; and “a sustained reduction in cases for at least 14 days.”

The White House’s guideline to lifting restrictions, Opening America Up Again, relied heavily on McClellan’s four standards. For example, the White House advised that economies shouldn’t be reopened until there was “a downward trajectory of documented cases within a 14-day period.” Fourteen days is important because it is believed the virus can incubate for two weeks before making someone ill, and asymptomatic individuals may transmit the virus. Think about this: anyone who gets sick now was infected after the shelter-at-home orders took effect at the end of March. (Neither Abbott’s office nor McClellan responded to a request for comment.)

Abbott said that businesses could open up even further as soon as May 18. If there isn’t an uptick in COVID-19 cases, the governor said he plans to allow most restaurants to move from 25 percent capacity to 50 percent capacity, and that he would then also allow barbershops, hair salons, gyms, and bars to open their doors to customers. At the same time, he said we should expect an upswing in the number of confirmed cases because there will be increased testing of people to determine whether they have COVID-19.

“It is only logical to see there be an increase in the number of people who test positive. So just because there may be an increase in the number of people who test positive, that alone is not a decisive criteria,” Abbott said. Instead, Abbott said he was more interested in hospitalization rates and deaths. He correctly pointed out that Texas’s hospital capacity has been more than sufficient to handle COVID-19. But hospitalizations and deaths are lagging indicators. It takes two to fourteen days for COVID-19 symptoms to manifest. If there’s another outbreak, new confirmed cases will surge before hospitalizations and deaths do.

May 18 is just around the corner. At a news conference Monday, the CEO of the Texas Restaurant Association noted that Mother’s Day (May 10 this year) is a big day for families to eat out. That’s just eight days before the phase two reopening, and COVID-19 symptoms take as long as fourteen days to manifest. If there’s a Mother’s Day outbreak, we may not know until well after May 18.

Even before Abbott’s announcement, you could sense isolation fatigue setting in—and not just from the relatively small recent protests at the state Capitol. People lined up for more than two hours to catch the ferry to the Bolivar Peninsula near Galveston. Zilker Park in Austin was filled with sun worshippers and dogs chasing tennis balls. It’s always difficult to keep a populace corralled for long periods to defend against an invisible foe. It was difficult during the so-called Spanish flu of 1918-1920. And isolation fatigue was one reason that deadly pandemic saw multiple waves of declining cases followed by new outbreaks.

The danger today is that restlessness and the pressures of keeping an economy shuttered are feeding a degree of magical thinking. During a round of radio interviews last week, Abbott said that a cure for COVID-19 will be available by the time the new school year begins in the fall. “Once we have an immunization we will be fully back to normal, but an immunization will not be in existence when the next school year begins,” Abbott told WBAP radio. “There will however be medicines you can take that will basically cure people who have COVID-19.” Abbott did not cite any evidence for this prediction, which is not supported by any of the leading experts on the virus.

At one point during his Monday news conference, Abbott said: “It’s hard to get rid of this virus because it is so contagious. So we’re not just going to open up and hope for the best.”  We can only hope that he’s right.

Here's What it Will Take to Live in a World with COVID-19 by Gideon Lichfield

However discomforting and unnerving, this very helpful and credible reporting is based on research that comes out of the Massachusetts Institute of Technology (MIT) and is consistent with other equally credible opinions like that of cancer Doctor Ezekiel Emanuel: U.S. Must Stay Locked Down For 12-18 Months Until There's A Vaccine.  It takes an unblinking look at living in a world with COVID over the next 12-18 months with significant implications for life in the free world, as we know it:

"Getting to normal, therefore, is not so much about getting back the old normality as it is about getting back the ability to know what is going to happen tomorrow. And it’s becoming increasingly clear what’s needed to achieve that kind of predictability. What we can’t predict, yet, is how long it will take political leaders to do what it takes to get there."

Though not mentioned, either online or mail-in voting should be our new default for all elections.  Among other things, it recommends mass surveillance which can hopefully be done without "Big Brother" creepiness.  Do take the time to read this in its entirety.  Relatedly, also read this earlier piece by Gordon Lichfield titled, "Social distancing is here to stay for much more than a few weeks. It will upend our way of life, in some ways forever."  

Felices pascuas!  Happy Easter and Happy Passover! "En lo que cabe," my family always says, meaning, "All things considered." Thanks to Rosanna Gomez Moreno​ for sharing.

-Angela Valenzuela

#StayHome #COVID19 #CoronavirusScience

Here's What it will take to live in a world with covid-19.

by Gideon Lichfield

Sunday, April 12, 2020

At some point covid-19 will be vanquished. By early April some 50 potential vaccines and nearly 100 potential treatment drugs were in development, according to the Milken Institute, and hundreds of clinical trials were already registered with the World Health Organization.

Even with all these efforts, a vaccine is expected to take at least 12 to 18 months to bring to market. A treatment may arrive sooner—one company, Regeneron, says it hopes to have an antibody drug in production by August—but making enough of it to help millions of people could take months more.

It could all be over more quickly if certain existing drugs, already known to be safe for other uses, prove effective in treating covid-19. Trials are now under way; we should know by the summer. On the flip side, it may be that only a vaccine delivers the knockout blow, and even then, we still don’t know how long one will stay effective as the virus mutates.

This is why everything feels unmoored and why everybody is stressed: because we can no longer predict what will be allowed and what will not a week, a month, or 12 months hence.

That means we have to prepare for a world in which there is no cure and no vaccine for a long time. There is a way to live in this world without staying permanently shut indoors. But it won’t be a return to normal; this will be, for Westerners at any rate, a new normal, with new rules of behavior and social organization, some of which will probably persist long after the crisis has ended.

In recent weeks a consensus has started to build among various groups of experts on what this new normal might look like. Some parts of the strategy will reflect the practices of contact tracing and disease monitoring adopted in the countries that have dealt best with the virus so far, such as South Korea and Singapore. Other parts are starting to emerge, such as regularly testing massive numbers of people and relaxing movement restrictions only on those who have recently tested negative or have already recovered from the virus— if indeed those people are immune, which is assumed but still not certain.

This will entail a considerable degree of surveillance and social control, though there are ways to make it less intrusive than it has been in some countries. It will also create or exacerbate divisions between haves and have-nots: those who have work that can be done from home and those who don’t; those who are allowed to move about freely and those who aren’t; and, especially in the US and other countries without universal health coverage, those who have medical care and those who lack it. (Though Americans can now get coronavirus tests for free by law, they may still wind up with hefty bills for related tests and treatment.)

This new social order will seem unthinkable to most people in so-called free countries. But any change can quickly become normal if people accept it. The real abnormality is how uncertain things are. The pandemic has undercut the predictability of normal life, the sheer number of things we always assume we will still be able to do tomorrow. That is why everything feels unmoored, why the economy is collapsing, why everybody is stressed: because we can no longer predict what will be allowed and what will not a week, a month, or three or six or 12 months hence.

Getting to normal, therefore, is not so much about getting back the old normality as it is about getting back the ability to know what is going to happen tomorrow. And it’s becoming increasingly clear what’s needed to achieve that kind of predictability. What we can’t predict, yet, is how long it will take political leaders to do what it takes to get there.

The background

First, let’s look at why simply waiting for a drug or vaccine isn’t a practical option.

One feature of the covid-19 pandemic is the speed with which the unthinkable has become the obvious. In mid-March, the British government was still advocating for letting most people go about more or less their normal daily business, while only the sick and the especially vulnerable isolated themselves. It changed tack rapidly after researchers at Imperial College London published a study showing the policy would lead to as many as 250,000 deaths in the UK.

That study made the case for what almost everyone now agrees is essential: imposing social distancing on as much of the population as possible. This is the only way to “flatten the curve,” or slow the spread of the virus enough to prevent hospitals from being overwhelmed, as they have been in Italy, Spain, and New York City. The goal is to keep the pandemic ticking along at a manageable level until either enough people have had covid-19 to create “herd immunity”—the point at which the virus is starting to run out of new people to infect—or there’s a vaccine or cure.

Waiting for herd immunity is not an idea most experts take seriously. But no matter what the final outcome, some degree of social distancing has to remain in place until we get there. A strict lockdown can slow new infections to a trickle, as it did in China’s Hubei province, but as soon as measures are relaxed, the infection rate starts to rise again.

In their report on March 16, the researchers at Imperial College proposed a way of alternating between stricter and looser regimes: impose widespread social distancing measures every time admissions to intensive care units (ICUs) start to spike, and relax them each time admissions fall. Here’s how that looks in a graph.

The orange line is ICU admissions. Each time they rise above a threshold—say, 100 per week—the country would close all schools and most universities and adopt social distancing. When they drop below 50, those measures would be lifted, but people with symptoms or whose family members have symptoms would still be confined at home.

What counts as “social distancing”? The researchers define it as “All households reduce contact outside household, school, or workplace by 75%.” That doesn’t mean you should feel free to go out with your friends once a week instead of four times. It means if everyone does everything they can to minimize social contact, then on average, the number of contacts is expected to fall by 75%.

Under this model, the researchers concluded, both social distancing and school closures need to be in force some two-thirds of the time— roughly two months on and one month off—until a vaccine or cure is available. They noted that the results are “qualitatively similar for the US.”

The researchers also modeled various less stringent policies, but all of them came up short. What if you only isolate the sick and the elderly, and let other people move around freely? You’d still get a surge of critically ill people at least eight times bigger than the US or UK healthcare system can handle. What if you lock everybody down for just one extended period of five months or so? No good—as long as a single person is infected, the pandemic will ultimately break out all over again. Or what if you set a higher threshold for the number of ICU admissions that triggers tighter social distancing? It would first mean accepting that many more patients would die, but it also turns out that it makes little difference: even in the least restrictive of the Imperial College scenarios, we’re shut in more than half the time. That means the economic paralysis lasts until there’s a vaccine or cure.

The tools

Those scenarios, however, assumed that being shut in applies equally to everyone. But not everyone is equally at risk, or risky. The key to getting to normal will be to establish systems for discriminating—legally and fairly—between those who can be allowed to move around freely and those who must stay at home.

Assorted proposals now coming out of bodies such as the American Enterprise Institute, the Center for American Progress, and Harvard University’s Edmond J. Safra Center for Ethics, describe how this might be done. The basic outlines are all similar.

First, keep as many people as possible at home until the rate of infections is well under control. Meanwhile, massively ramp up testing capacity, so that once the country is ready to relax social distancing rules, anybody who asks for a test—and some who don’t—can take one and get the result within hours or, ideally, minutes. This has to include testing both for the virus, in order to detect people who are currently sick even if they don’t have symptoms, and for antibodies, in order to find people who have had the disease and are now immune.

People who test positive for antibodies might be granted “immunity passports,” or certificates to let them move freely; Germany and the UK have already said they plan to issue such documents. People who test negative for the virus would be allowed to move around too, but they would have to get retested regularly and agree to have their cell phone’s location tracked. This way they could be alerted if they come into contact with anyone who has been infected.

This new social order will seem unthinkable to most people in so-called free countries

This sounds Big Brotherish, and it can be: in Israel, such automated monitoring and contact tracing is being done by the domestic intelligence agency, using surveillance tools created for tracking terrorists. But there are less intrusive ways of doing it.

The Safra Center, for example, outlines various schemes for “peer-to-peer tracking,” in which an app on your phone swaps encrypted tokens via Bluetooth with any other phones that spend some minimum period of time nearby. If you test positive for the virus, you put that information into the app. Using the tokens your phone has collected in the past few days, it sends alerts to those people to self-isolate or go get tested. Your actual location doesn’t have to be tracked, only the anonymized identities of the people you’ve been near. Singapore uses a peer-to-peer tracking app called TraceTogether, which sends the infection alerts to the health ministry, but—in principle at least— such a system can be set up with no centralized record-keeping at all.

There also needs to be nationwide data-gathering and analysis to better understand how the virus is spreading and spot high-risk areas that might need more testing or medical resources, or another quarantine. This strategy has to include serological surveys—random testing for antibodies to find out how widely the virus has already spread. Some other ways to gauge its prevalence without spying on people directly might be to crowdsource the information using sites like covidnearyou.org, infer it from the volume of Google searches for covid-19 symptoms in different places, or even look for the virus in samples of sewage.

It’s also important to make sure people who have tested positive or been exposed are staying in quarantine. This, however, seems hard to do without more direct surveillance. Countries like Singapore and South Korea use various means, such as making people share their location via WhatsApp or download a specialized tracking app. Whether the US or European countries could impose (let alone enforce) that kind of control isn’t clear. Without it, we have to rely on people to be responsible citizens and self-isolate when necessary.

The point is, there are more and less creepy ways of doing all this, and the crisis could catalyze a broader conversation about how to use people’s data for the collective good while protecting the individual.

The hurdles

Regardless of the methods chosen, the goal is the same: after a couple of months of shutdown, to begin selectively easing restrictions on movement for people who can show they’re not a disease risk. With good enough testing capacity, data collection, contact tracing, enforcement of or adherence to quarantines, and coordination between the federal, state, and local governments, local outbreaks might be contained before they spread and force another national shutdown.

Gradually, more and more people would be able to return to some semblance of normality. It would still be a far cry from the packed bars and sports arenas of the past, but it would be a less unbearable way to wait for the discovery of a vaccine or cure. More important, the economy could start ticking back to life.

This depends on a lot of things going right, though. First, the initial shutdown probably needs to be harsher than it currently is in the US. At the time of writing some US states still had no stay-at-home orders, few cities were enforcing those orders, and there were no restrictions on travel between cities or states. In China, by contrast, cities in Hubei province spent some two months in strictly enforced lockdown, with public transport cut off and inter-city movement restricted.

Second, by some estimates, millions of virus tests a day, promptly performed, may be required to properly keep tabs on the pandemic in the US. By April 8 the country was testing around 150,000 people a day, and many results were taking more than a week to come back.

Third, testing for antibodies is still in its infancy, and most of the tests currently in development still return fairly high rates of both false positives and false negatives, according to the Johns Hopkins Center for Health Security. A plan to order millions of home test kits for the UK ran into trouble after experts found they might work as little as half the time.

Fourth, the US in particular has precious little coordinated national strategy. The chaotic management of the crisis by the Trump administration, the separation of powers between the federal government and the states, and the fragmented nature of privatized health care make it unclear how systems for automated contact tracing, quarantine enforcement, or immune certification will emerge.

That means a reopening of the US in June is optimistic, to say the least, and a reopening by April 30, as President Donald Trump was still hoping for in early April, is a fantasy. But Trump, along with his alter ego, Fox News, has gradually and reluctantly been moving toward a more realistic stance about the pandemic. By the end of March the White House had adopted projections of the death toll in line with those of many experts, even if those projections still assumed stricter social distancing measures than the federal government is currently calling for. As the pandemic spreads further into the country and starts to pummel the more Republican-leaning states, the president’s interests may start to align more closely with those of the country as a whole.

The outcome

This, then, is what passes for optimism in these grim times: the hope that while the days are still warm, and after tens if not hundreds of thousands of lives have been lost that could have been saved with quicker action, some of us will be able to start crawling out into the sunlight. We’ll emerge into a world in which people give each other wide berths and suspicious looks, where those public venues still in business allow only the thinnest crowds to congregate, and where a system of legal segregation determines who can enter them. Millions will still be out of work and struggling to get by, and people will watch nervously for signs of a new flare-up near them.

But as you contemplate that future, spare a thought for the billions of people in the world for whom even social distancing and basic hygiene are unaffordable luxuries, let alone testing, treatment, and technologically advanced governments. The pandemic will roar through the slums of the world’s poorest countries like fire through sawdust. In their considerably younger populations, it will probably be less deadly than in the rich world. But an unchecked pandemic there may also oblige other countries to keep their borders closed for longer to protect their own populations.

A miracle may still happen. Perhaps a readily available drug will work. Perhaps testing will show that the virus is far more widespread and less deadly than we thought. It’s worth hoping for these things, but we can’t bank on them. What we can expect is to have an increasingly clear picture, as the days go by, of how this will play out if we take the right steps.

That’s as normal as things are going to get for a while.

·        

The Sociology of Surviving the Coronavirus by Amitai Etzioni

We cannot under-estimate the harmful effects of social isolation.  Social media can help combat this—as long as those aspects aren't toxic, I might add.  We at the university just had our first departmental meeting remotely.  It felt really good to see everybody in our Zoom Conference call. This is a "new normal" for us all. We're all coping.  

Let's make it a daily practice to share words of love, caring, and encouragement with those around us—even if virtually so. 💗

-Angela Valenzuela

March 16, 2020  

The Sociology of Surviving the Coronavirus

The much-maligned social media realm can help people avoid the detrimental effects of social isolation during this pandemic. Otherwise, the psychological effects of isolation could further compound the multi-faceted damage caused by the deadly virus.

by Amitai Etzioni

There is another name for social distancing—a mainstay of the campaign to contain the spread of the coronavirus—social isolation. Much has been made of the economic effects of COVID-19. However, we should not overlook the social and psychological effects. The containment campaign basically greatly reduces the contacts people have with one another, by canceling numerous social events and urging older people and those with special health conditions not to leave home. Many of these elders live on their own, as their partners have died. For all, it means fewer opportunities to see family and friends. One should also note that many people have social contacts at work, so teleworking—introduced widely in an effort to stop the spread of disease—undermines these contacts.

The Effects of Isolation

Isolated individuals exhibit major health problems. James House, Karl Landis and Debra Umberson found that “[m]ore socially isolated or less socially integrated individuals are less healthy, psychologically and physically, and more likely to die.” In an article based on her 2017 testimony before the U.S. Senate Aging Committee, Julianne Holt-Lunstad reports that, physically, “[l]acking social connection carries a risk that is comparable, and in many cases, exceeds that of other well-accepted risk factors, including smoking up to 15 cigarettes per day, obesity, physical inactivity, and air pollution.” She also notes that people who are isolated may have less effective immune systems, higher blood pressure, and increased inflammation, and they are less likely to follow medication and treatment plans. John Cacioppo and Louise Hawkley demonstrated that social isolation engenders a ripple of mental and physical health risks, including depleted ability to cope with stressors, poor sleep, and slower healing. Holt-Lunstad finds that “those who are isolated are at increased risk for depression, cognitive decline, and dementia.” Hawkley and Cacioppo  suggest “ that loneliness is the social equivalent of physical pain, hunger, and thirst.”

The new rules are particularly hard on those who left their elders or partners in nursing homes—those who used to visit their kin daily are now shut out. The virus also poses heart-wrenching moral dilemmas around the question of whom to see and whom to avoid. One example will stand for all the others: A family's college-age son is in Italy. He felt well and wanted to rush home, just before Italy locked down. His family urged him to stay, lest he brings the virus home and infects them—leaving him to fend for himself in highly-infected Italy!

The much-maligned social media realm can help people avoid the detrimental effects of social isolation during this pandemic. The World Health Organization’s March 6 release of “Mental Health Considerations during COVID-19 Outbreak” suggests that people in isolation “stay connected via e-mail, social media, video conference and telephone.” While some might scoff at this form of connection, there is research that supports the idea that technology can help people to feel less lonely. According to research conducted for Pew, “[t]he average user of a social networking site has more close ties and is half as likely to be socially isolated as the average American.”  Weixu Lu and Hampton found that “Facebook status updates and private messaging are independently associated with perceived support” and Hampton reports that, over time, the use of social networking sites is correlated with reduced psychological distress. These benefits are not limited to those who were practically born with a smartphone in their hands. Two European studies found positive effects of social network use by older populations: André Hajek and Hans-Helmut König report that feelings of social isolation typically occur less frequently among those ages forty and older who report daily use of social networks than among their peers who use social networks less often or not at all. Orsolya Lelkes reports that “social isolation is lower among internet users aged 65 or older.” Inventive Italians add another touch: isolated in their homes, they are getting together on their porches—to sing. In short, people confined to their homes can reach out to others and improve their psychological condition.

Amitai Etzioni received his PhD in sociology from the University of California at Berkeley in 1958 and served as a professor of sociology at Columbia University, Harvard, and The George Washington since then. 

The Dos and Don’ts of ‘Social Distancing’ Experts weigh in on whether you should cancel your dates, dinner parties, and gym sessions.

Friends,

I found this piece in The Atlantic helpful on the subject of social distancing and what it actually means in practice.  If you have to make a run to the grocery store, it is best to do so when it opens, closes, meaning hours when the least number of people are there. Other helpful questions answered, too.

-Angela Valenzuela

#coronavirus

The Dos and Don’ts of ‘Social Distancing’

Experts weigh in on whether you should cancel your dates, dinner parties, and gym sessions.

KAITLYN TIFFANY

MARCH 12, 2020

The Centers for Disease Control and Prevention has issued guidelines for “community mitigation strategies” to limit the spread of COVID-19, the disease caused by the coronavirus, which include recommendations for “social distancing”—a term that epidemiologists are using to refer to a conscious effort to reduce close contact between people and hopefully stymie community transmission of the virus.

But what exactly does “social distancing” look like for a woman trying to go about her life while staying healthy and helping keep the people around her healthy? Even detailed instructions are difficult to sift for actionable advice. If I have a fourth date tonight, do I go? If I’m invited to a wedding in two weeks in another state, is it too late to cancel? If we’re on lockdown, and I live alone, can I walk to my friend’s apartment when I feel sad? If I end up officially quarantined, can I walk around the park at night for some fresh air?

The CDC guidelines acknowledge factors like the size of a community, its population density, its access to health care, and caveats that social-distancing measures can “be scaled up or down depending on the evolving local situation.” There are conflicting messages coming from media and people’s peers: On Reddit, young people are signing a “self-quarantine manifesto” while, at a press conference, the mayor of New York City is telling people to continue visiting bars and restaurants as normal, to protect the local economy.

Read: Cancel everything

So I took my personal questions to a series of public-health experts. “I think it’s a hard time because many of the recommendations we’re making are about increasing the distance between people, but of course, being close to people is what makes life a pleasure,” Carolyn Cannuscio, the director of research at the Center for Public Health Initiatives at the University of Pennsylvania said in a phone call. “So this is going to be a very difficult time. No question.”

If you’re confused about what to do right now, you’re not alone—even these experts occasionally disagreed on the answers to my questions. Where there were discrepancies, I’ve included all the different answers as fully as possible. This guide is aimed toward those who are symptom-free and not part of an at-risk group, with an addendum at the end for those in quarantine. If you are symptom-free but are over 60 years old; have asthma, heart disease, or diabetes; or are otherwise at risk, experts recommend defaulting to the most conservative response to each of these questions.

There is a general consensus that while young and healthy people who are at lower risk for personally suffering severe illness from the coronavirus don’t have to be locking themselves in their homes for the next month, they do need to dramatically alter their daily lives, starting now.

If I’m Symptom-Free:

SHOULD I BE AVOIDING BARS AND RESTAURANTS?

Cannuscio: People should avoid gathering in public places. People should be at home as much as possible. The measures that have worked to get transmission under control or at least to bend the curve, in China and South Korea, have been extreme measures to increase social distancing.

Crystal Watson, a senior scholar at the Johns Hopkins Center for Health Security: It depends on local context. If we’re in a situation where the disease has been shown to be spreading widely, I think people will start to want to stay home and not go out into crowded settings.

Albert Ko, the chair of the epidemiology department at the Yale School of Public Health: If you go to a crowded bar where you’re up one against another, that’s a lot different from going to a bar where you’re spread out. The CDC recommendations are to keep six to 10 feet away from other people. Bottom line, there’s no absolute indication not to go to bars and restaurants, but in practicing good public health—which is kind of a responsibility for everybody in the country—really think about how we can decrease those close contacts.

CAN I HAVE A SMALL GROUP OF FRIENDS OVER TO MY HOUSE FOR A DINNER PARTY OR A BOARD-GAME NIGHT?

Watson: I think small gatherings are probably okay as long as nobody has symptoms, respiratory symptoms. As soon as someone seems sick, you should probably not get together.

Ko: We’re in a gray zone now. The public-health imperative is to create social distance; that’s the only way we’re going to stop this. Think about having those get-togethers but practicing good public health: not sitting very close, trying to keep distance. Wash your hands; avoid touching your face. There are places on the board game that people are constantly touching—routinely disinfect [those, as well as] doorknobs, the bathroom faucets, those types of things. There’s no absolute rule about what works, but what we do know is that decreasing the size of those gatherings, increasing the distance, practicing good hygiene will go a long way.

Cannuscio: I would recommend that people minimize social contact, and that means limiting all social engagements. That includes intimate gatherings among friends. I think the exception is if two households are in strict agreement that they are also going to reduce all outside contact and then those two households socialize together, to support one another. I can see social and mental-health advantages to that kind of approach.

SHOULD I STOP DATING?

Ko: Dating is usually one person and another person. What we’re really worried about in terms of public health are these large gatherings where you have people crowded together, and you can have what we call super-spreading events. The risk of those goes up exponentially the larger the size of the gathering. Dating is at the other end. I think you can still date.

Watson: I think dating is okay, if you believe with reasonable confidence that you’re both well. I think we’re humans and we need human interaction; I think that’s important for our sanity. It’s important to focus on [avoiding] large crowds and indoor activities where you have lots of people touching the same surfaces.

Cannuscio: It is a time to be very cautious about initiating contact with new people. This seems like a great time to get creative with your text messages. [Or] take it to FaceTime or a phone call.

CAN I GO TO THE GYM?

Ko: If you do go to the gym, again, maintain distances. Disinfect places in the gym people are always touching. Wash your hands regularly. Much of the transmission is person to person with people coughing, sneezing, or touching their nose and mouth and touching somebody else. You can get transmission on surfaces; that’s probably a little bit lower-risk, but we still should disinfect surfaces that we touch.

Cannuscio: If you’re going to go to the gym, try to go at a time when there are very few people there and definitely wipe down the equipment. However, as the weather warms in many parts of the United States, I would instead recommend that people go outside for walks or runs or bike rides in areas where there are not other people. This is really about depriving the virus the opportunity to move from one person to another.

Read: Here’s who should be avoiding crowds right now

SHOULD I BE WORRIED ABOUT GOING TO THE GROCERY STORE?

Cannuscio: I would say try to shop at times when there are very few other shoppers there. That [could mean] going first thing in the morning when the store opens, or late at night. I think many people will rely on delivery, and that’s just the nature of our lives right now. For delivery workers, I would say, leave the food on the doorstep and ring the bell, rather than interacting face-to-face with the person who’s ordered the food.

SHOULD I TAKE PUBLIC TRANSPORTATION?

Cannuscio: First of all, people who have the opportunity or the option of working at home should absolutely use that option right now. For people who have essential functions and have to be at work, if they have any flexibility in their schedules they should try to ride at non-peak hours. On subways or buses, people should try to stand as far away from other people as possible. I think it’s important for planners to think about, for example, putting more buses on the most heavily traveled routes, to maybe thin out the crowds on those buses. In cities where it’s possible to walk, that would be a better option.

For people who can afford to use ride-sharing services, you’re limiting the number of people you’re in contact with as the rider, so to me that seems like a reasonable step to take. Of course, I worry about all those drivers who have people in and out of their cars all day long.

And of course, everyone should be using good hand hygiene and respiratory etiquette. If you have to cough, cough into your elbow. And I can’t believe I have to say this, but I’ve been in public places where people have been spitting, in parks or on the sidewalk. I would ask people not to spit!

Watson: It’s hard to say “Don’t take public transit,” because a lot of people rely on it to get to work. If you don’t have to and you can drive, it’s probably a good idea. It will help other people who have to take public transit for their livelihoods to do so and do so more safely.

SHOULD MY FAMILY BE CANCELING EVENTS LIKE BIRTHDAY PARTIES AND WEDDINGS?

Watson: It’s hard to ask everyone if they’re feeling sick and harder to know what their exposures have been. I would take a look at who is invited to the party. Are there people who are very vulnerable? Older people, people who have underlying health conditions, pregnant women? If that’s the case, I would err on the side of caution. I don’t want to tell somebody to cancel their wedding. That would be terrible. But I think you have to look at the situation, maybe ask guests who are feeling ill not to come. If it’s being held in a community where there’s widespread disease, then it might be worth [reconsidering the event].

Ko: If those events can be postponed, I think that’s certainly productive. If a wedding can’t be postponed, there are things you can do. Hold it in an open space, where people are spread apart. You have to be really careful about exposures and really practice social distancing from the elderly.

Cannuscio: One of the best ways we can show love to the people we care about is to step back and to stay away. In many cases that takes courage, and it takes speaking out over these social norms that dictate that we should be polite and we should be together and we should celebrate and gather. Really seriously consider whether now is a joyful time to gather family members for a wedding celebration.

Read: The worst outcome

SHOULD I STOP VISITING ELDERLY RELATIVES?

Watson: I think we should start limiting visitation to people who are in assisted-living facilities and nursing homes. I know that’s really tough, and maybe setting things up so you can visit them virtually is a good idea. [That way], they can see you and say hello, [without putting] them at extra risk.

Cannuscio: I think if we are fortunate enough to live near our elders and we get into the mode of seriously isolating our own families, then one person should be designated to go and visit. If we’re not in a situation where we can truly limit our own social contact, then we will be putting that elder at risk by going to visit.

SHOULD I BE CANCELING HAIRCUTS AND OTHER NONESSENTIAL APPOINTMENTS?

Watson: Those are more one-on-one interactions. I think there’s a lower likelihood that exposure is going to occur that way. I don’t think that’s a big concern.

Cannuscio: I would say hold off on your haircut and then when you go back, when it’s clear that we have vanquished this foe, everybody please give your hairdresser extra, extra tips. I hope that policies will be put into place to protect the paychecks of people who will suffer during this period.

SHOULD I AVOID COMMUNAL SPACES IN MY APARTMENT BUILDING?

Cannuscio: Try to schedule your use of those common spaces so you’re going at times when other people aren’t around. If you know there are not a lot of people in the laundry room or mailroom at 6 a.m., go at 6 a.m. People will be inconvenienced, but it’s important to try to spread ourselves out.

SHOULD I LIMIT PHYSICAL INTERACTION WITH MY PARTNER, OR OTHER PEOPLE I LIVE WITH?

Ko: That’s really hard to do. Again, what we’re really worried about is large gatherings. In the home, close contact is almost inevitable.

Cannuscio: I would say if you’re in a steady, monogamous relationship and you and that other person are limiting your social contacts, then be as intimate as you want to be.

Watson: If you get sick, try to maintain some distance. Otherwise, households should go about their normal business.

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If I Get Symptoms or Am Exposed to Someone Who’s Sick:

IF I AM WAITING OUT A 14-DAY QUARANTINE, CAN I HAVE VISITORS AS LONG AS THEY STAND FAR AWAY FROM ME?

Cannuscio: No, quarantine means “stay away from other people.” You shouldn’t have visitors.

Ko: Under quarantine, people really shouldn’t enter the home or be in the same physical space.

Read: What will you do if you start coughing?

CAN I WALK AROUND OUTSIDE AT ALL WHEN I’M UNDER QUARANTINE?

Cannuscio: For people who live in areas that are not densely populated, walking around in their yard is probably safe. The idea is that they should not come into contact with any other people. They need to be strict about it. We are not going to defeat this and halt transmission if people loosely interpret what it means to self-quarantine or self-isolate.

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KAITLYN TIFFANY is a staff writer at The Atlantic, where she covers technology.