Coronavirus Is Not a Bioweapon—but Bioterrorism Is a Real Future Threat The pandemic’s effect on the world isn’t that of a conventional attack on government targets or the military. Rather, it’s a widespread and indiscriminate attack on global citizens and the economy. by Trushar R. Patel and Michael Hilary D'Souza

The ongoing COVID-19 pandemic has far-reaching implications as Canadians face unemployment, diminishing returns on their purchasing power and the prospect of an ensuing recession.

These challenges will be faced in the coming year despite stimulus packages announced by the Canadian government to mitigate the downturn. Unsurprisingly, comparisons with the Great Depression and the 1918 flu pandemic have drawn parallels to receding markets and the pandemic.

Concerns over coronavirus being a bioweapon have flourished, despite being a novel, naturally occurring pathogen dispersed globally though free trade and international travel.

However, an equally dangerous incident involving bioterrorism should not be ignored.

The pandemic’s effect on the world isn’t a conventional attack on government targets or the military. Rather, it’s a widespread and indiscriminate attack on global citizens and the economy. This outbreak has directly impacted the lives of billions of people, making it the most effective model for future terrorist activities and a new model for circumventing the conventions of modern warfare.

Striking at international vulnerabilities

An act of bioterrorism could have the same effect on our lives and the economy. Terrorist organizations actively seek to cripple a target economy through the employment of simple technologies in coordinated and sophisticated attacks on key infrastructure. This has normally ranged between simple targeted shootings and improvised explosives but can also include biochemical weapons such as mustard gas.

Locally, we are aware that Canada’s economy is especially vulnerable to sudden global shockwaves. This is largely because of our subsistence on resource development projects like oil and natural gas, and our bottle-necked relationships with the United States.

A little less than 10 per cent of Canada’s economy is dependent on mining, agriculture and resource extraction, combined with another 10 per cent contributed by manufacturing. A strike to any of these industries would ripple insecurities across the country and hurt a fifth of Canada’s GDP.

For instance, a key infrastructure in Canada is the rail corridor that operates from coast-to-coast. The corridor is already overburdened with the transport of crude oil and mired in rail derailments that cause disruptions to the national economy. The combined price drop in oil and the Canadian National Rail blockades initiated by the Wet’suwet’en solidarity movement against the Coastal GasLink Pipeline created market volatility and invariably shutdown Canada’s ability to transport goods, causing temporary layoffs and concern from foreign investors developing the project.

Although the economic impact of the blockades was low compared to the pandemic, the effect of disruption is important. It demonstrates the ease with which foreign and domestic terrorists can operate to undermine Canadian sovereignty and stability by targeting a few, important Canadian industries.

The effect of the blockades stalling trade and forcing temporary layoffs is similar in consequence to the imposed self-isolation preventing Canadians from working, generating income and consuming commodities.

Consistent unemployment and spending reductions in Canada can also produce a snowball effect that inches towards recession. Regardless of its size, a targeted attack can disrupt a nation enough to create instability and panic, which is the intent of terrorist groups that cannot compete equally with industrially backed, modern militaries.

Opportunity and expertise

The feasibility of designing and dispersing biological weapons varies in difficulty depending on the biological agent in question. For instance, Bacillus anthracis, an exceptionally deadly and versatile pathogenic bacterium that causes the disease anthrax, is naturally occurring in the environment and can infect humans and animals. Anthrax has recently emerged from thawing permafrost due to the effects of climate change, and manages to persist in harsh climates and environments demonstrating its versatility.

Acquiring anthrax is relatively easy and its highly infectious spores can enter the body through inhalation of aerosols or ingestion via contaminated water supplies. Consequently, anthrax is considered one of the leading potential bioweapons. In 2001, five people in the United States died after receiving mail contaminated with anthrax — no one was caught or charged.

Conversely, the employment of synthetic biology to engineer novel bioweapons from pre-existing pathogens using CRISPR or DNA synthesis is far more demanding in terms of laboratory requirements and expertise.

The manipulation and handling of these agents have been made more accessible by biotechnology companies competing aggressively for the attention of academic, corporate and government funding.

With strict deadlines and finite resources, researchers value methods that provide reproducible and reliable results. This has been especially encouraging for the development of new technologies like CRISPR, whose competitive market has made gene-editing accessible and cost effective.

Researchers have also supplemented their laboratories 3D-printed equipment, making complex instruments that were once costly and out-of-reach easily accessible to anyone interested in biotechnology. This allows the convenient development of weapons to occur anywhere from stringent, regulated laboratories to remote facilities and even in one’s own garage.

While countries like the U.S. and Russia inherited advanced biological weapons programmes from the Cold War, rogue nations like North Korea and terrorist organisations like al-Qaida are actively seeking to develop programs and infrastructure for their own use and deterrence against foreign interference. With easily obtainable and simple technologies, the ability to invest in an underground bioweapons program is widely available.

All that is necessary to bridge the gap is talent.

A common myth appears to exemplify terrorist members as being uneducated individuals. However, at its peak, the Islamic State of Iraq and the Levant (ISIS) recruited a variety of educated professionals ranging from engineers to medical doctors. ISIS operated in the Middle East as any nation state would, with municipal bureaucracies, tax collection, road-building, infrastructural developments and hospitals.

Terrorist organizations tend to have the same infrastructural and scientific capabilities as modern industrial nations, allowing them to potentially develop biochemical arsenals. The infrastructure requirements for biological weapons programs are also made easier by being comparatively cheaper and more versatile than a nuclear arsenal. This is largely because they can be masked by developments in medical industry, health and agricultural research.

United against future threats of bioterrorism

Unfortunately, the threat of bioterrorism requires countries to work together proactively and develop collective strategies to thwart the next deliberate — or even unintended — outbreak. The challenge wouldn’t just be about ensuring global compliance with the United Nations Biological Weapons Convention. Rather, nations will need to re-evaluate how they manage the business of biotechnologies to prevent them from falling into the wrong hands. This would involve a tough foreign policy and trust-based relationships with allies to share data on potential insecurities and risk personnel.

Meanwhile, governments and international agencies will need to work collaboratively on medical research science, since we’ve learned from our shared experience with coronavirus that outbreaks don’t just affect one nation.

Coronavirus: Why the Sudden Loss of Smell Is a Reason to Self-Isolate Waking up and not being able to smell the coffee could be a sign of COVID-19. by Jane Parker, Carl Philpott and Tristram Wyatt

Waking up and not being able to smell the coffee could be a sign of COVID-19. The World Health Organization recently announced that a sudden loss of sense of smell (anosmia) should be added to the symptoms of COVID-19. The UK government has just done that, stating: “From today, all individuals should self-isolate if they develop a new continuous cough or fever or anosmia.”

The inclusion of sudden anosmia is important as it may be an early – and sometimes the only – symptom of COVID-19 infection. It is also a symptom, like fever, that we can detect ourselves without a laboratory test. The indications are that if we were all to respond to this cue by self-isolating, we could reduce the spread of the virus.

An early clue that a loss of smell might be related to COVID-19 came in early March 2020 from a Facebook post about an ear, nose and throat (ENT) doctor who suddenly lost his sense of smell. What followed was a gradual accumulation of evidence linking anosmia to COVID-19.

Membership of closed Facebook groups dedicated to those experiencing smell loss grew exponentially, Google searches for “anosmia” increased, and high-profile cases were reported in the news. ENT doctors saw an increase in patients reporting anosmia and started to publish case studies based on the experience of their patients – many of them healthcare professionals. One, a neurosurgeon, reported anosmia with no other symptoms. Two days later he tested positive for COVID-19.

The sudden onset of anosmia was described as a new finding that may distinguish COVID-19 from the common cold or flu. An early statement was issued by ENT-UK and the British Rhinology Society calling for anosmia to be recognised as a marker of the virus. However, while the case studies and anecdotes are compelling, they lack the large datasets of a scientific study.

The first large dataset came from Iran. It was a home-based study of 10,000 people showing a correlation between anosmia and COVID-19. Results from the second large dataset were published by a team based at King’s College London. Their COVID Symptom Study app showed that 65% of those who tested positive for the disease also had a loss of smell and taste, and this symptom was by far the best predictor of COVID-19. And preliminary results from the first survey of the Global Consortium for Chemosensory Research (GCCR) showed that those reporting COVID-19 symptoms had an average drop of 80% in their ability to smell.

These surveys add weight to the anecdotal evidence, but they have limitations. The main one being that they are based on people self-reporting symptoms – that is, their ability to smell was not clinically assessed.

On the other hand, studies based in hospitals and ENT clinics provide valuable evidence where the COVID-19 status and case histories can be determined with more certainty. The first came out of China, where researchers reported a modest 5% of patients had an impaired sense of smell. Studies in France (417 patients), in Italy (202) and in the US (102), on patients all testing positive for COVID-19, found a loss of smell in 86%, 64% and 68% of cases, respectively.

Results from clinical studies appear at the rate of one every few days and the conclusions overwhelmingly support the claim that anosmia is associated with COVID-19. The most revealing of these was another study from Iran that measured sense of smell using a recognised scratch and sniff test. In this case, 59 out of 60 COVID-19 patients had a decrease in their sense of smell. Three systematic reviews of the recent evidence have concluded that there is a strong link between COVID-19 and anosmia.

Early warning sign

It is important to understand the timings of smell loss in relation to other symptoms. Several studies report the onset of anosmia before other symptoms, or as the only symptom. Indeed, a US study found anosmia appearing as the first symptom in 27% of their responses. A Chinese group showed you can still be infectious, even if anosmia is your only symptom, but this is an area when more data is required fast. The relationship between anosmia and infectiousness is still unclear, but it is certainly an early warning sign that other symptoms may follow.

Considering the combined strength of all the above, there is little doubt that sudden loss of smell is related to COVID-19. But we still need a strict evidence-based approach involving objective smell testing and evidence of the mechanisms involved, some of which is emerging. In the meantime, we would all be well advised to treat a sudden loss of the sense of smell as an indication we should self-isolate.

Coronavirus Is Increasing the Toll on America's Caregivers America's 53 million caregivers face new worries due to the coronavirus, including whether they can still assist their vulnerable relatives and friends. by Erin E. Kent

I'm studying how the COVID-19 pandemic is changing caregiving.

Immunocompromised people, seniors with dementia and anyone with a chronic disease are more likely to experience the most severe COVID-19 symptoms. Caregivers face new worries due to the coronavirus, including whether they can still assist their vulnerable relatives and friends and what they should do if they themselves or someone they live with gets sick.

This quandary affects about 21.3% of Americans. The total number of Americans doing this unpaid work has reached an estimated 53 million in 2019, according to the latest data collected by the National Alliance for Caregiving, an advocacy and research organization, and AARP. That number, which excludes people caring for children without disabilities, is up from 43.5 million, the previous estimate made in 2015.

Caregivers support their loved ones and friends by voluntarily performing an array of duties. They help with activities of daily living, such as eating and getting dressed, along with a range of medical needs. They change bandages, make sure the person they’re caring for is taking their drugs and monitor symptoms.

The report also observes that more than 6 in 10 caregivers are women, their average age is 49 and about 1 in 10 is a college student.

Caregiving under ordinary circumstances could take at least 23 hours per week, with few breaks and little support. With COVID-19 social distancing measures, restrictions on getting more help at home is making caregiving even more challenging.

The pandemic is also increasing the toll that caregiving takes on the health and finances of caregivers.

And even before COVID-19 arose, about 1 in 4 caregivers were struggling to coordinate health care from multiple providers, up from 1 in 5 in 2015. Almost half have taken at least one financial hit as a result of their caregiving, the new report found.

Still, until now the government hasn’t done much to support caregivers. Congress did work some funding for them into the $2 trillion relief package known as the Coronavirus Aid, Relief and Economic Security (CARES) Act – $100 million for services to support caregivers but the exact details remain to be seen.

Several organizations provide caregivers with resources and guidance on people caring for others who have contracted COVID-19, but advice is not enough.

I believe that health care systems ought to take steps to make sure that caregivers are adequately protected with the masks and other personal protective equipment they need at home, and have access to telehealth services for their loved ones and check-ins from clinicians who can ensure they have what they need to take good care of themselves.

Obamacare Isn’t Enough to Protect Americans From Coronavirus A professor of public policy warns millions will be left without coverage. by Simon F. Haeder

The loss of 31 million jobs due to coronvirus has an added downside: 27 million have lost job-based health insurance. The worst may still lie ahead. One study estimated that 25 to 43 million people could lose coverage from their employer.

The situation for many Americans feels dramatic. Fortunately, the limited U.S. safety net will be able to cushion some of the fallout for almost 80% through programs like Medicaid, the Children’s Health Insurance Program and the Affordable Care Act marketplaces. And, of course, all preexisting conditions are still required to be covered by all insurers.

Yet millions will be left without coverage. As a professor of public policy, I believe there are four things you need to consider if you’ve been laid off, or if you didn’t have health insurance before the pandemic.

What do I do if I’ve been laid off and lost coverage?

The good news: For many who have lost their employer-provided coverage, a number of alternatives may exist.

For some, they might now be able to join their spouse’s insurance. Others may be able to maintain their previous coverage through COBRA, albeit without the financial subsidy from their employer. This option can get expensive very quickly. Currently, average premiums in the U.S. for individuals amount to US$7,188. The number increases to $20,576 for a family of four. And COBRA adds an additional 2% of premiums for administration.

Due to the loss of income, people in states that expanded Medicaid under care of the ACA could become eligible for Medicaid coverage. In those states, individuals and their families qualify if their income falls below 138% of the federal poverty line. For a family of four, this currently amounts to roughly $36,000. In states that did not expand Medicaid, eligibility rules vary widely but are often quite restrictive.

Individuals who do not qualify for their state Medicaid program may find an alternative in coverage purchased on the ACA insurance marketplaces. Here individuals between 100% and 400% of the federal poverty line are eligible for premium support. Those on the low end of the guidelines are also eligible for out-of-pocket support.

Unfortunately, the decision of many states not to expand their Medicaid programs may leave millions of Americans ineligible for public coverage. They fall into the so-called coverage gap. They make less than the 100% of federal poverty line that makes them eligible for ACA marketplace subsidy. Yet they also make too much to qualify for the restrictive state Medicaid program. This situation applies to nonparent adults in 10 states, including Texas, Oklahoma and Mississippi.

Importantly, coverage may be available for the children of those who have lost their previous insurance through the Children’s Health Insurance Program. Eligibility limits, even in nonexpansion states, are significantly higher.

Finally, individuals can purchase short-term limited duration insurance. While premiums for this type of coverage are significantly cheaper than for ACA-compliant products, their coverage comes with significant gaps. That is, most preventive services, treatment for conditions like cancer or even prescription drugs likely will not be covered. They also require medical underwriting.

What if I didn’t have insurance in the first place?

A global pandemic seems like a particularly bad time to go without coverage. Yet we know that millions of Americans are eligible for public coverage but remain unenrolled. For many of them, many of the same options described above may apply, including Medicaid, CHIP, spousal coverage and short-term limited duration health plans.

The situation is more complex for those seeking to purchase insurance on their own. The ACA insurance marketplaces generally require that individuals purchase coverage during their open enrollment period. This occurs generally in November and December. The requirement is intended to keep insurance markets stable and not simply allow individuals to obtain coverage only when they fall sick.

In the wake of the coronavirus pandemic, at least nine states have made an exception and reopened their marketplaces temporarily. These include Colorado and Connecticut.

What if I fall sick and don’t have insurance?

If you fall sick and need medical help but are currently uninsured, you should not hesitate to seek care.

Many providers, particularly hospitals and federally qualified health centers, will actively seek to enroll you into public coverage like Medicaid. Importantly, Medicaid coverage in most states can be applied retroactively for three months. However, a few states like Arizona and Iowa have obtained permission to exclude this benefit.

Even then, many states have longstanding protections for uninsured individuals that requires providers to use so-called sliding scales, the adjustment of fees based on income. Others have local programs that may help pay for your care. The CARES Act also provides reimbursement for some COVID-19-related care directly to providers.

Importantly, if you get a bill, try to negotiate with the provider. Legal aid societies across the country are there to help in this process.

How the ACA lawsuit may impact health insurance coverage

From a policy perspective, the coronavirus pandemic starkly highlights the need for a strong safety net. It is also offers a reminder of the benefits that the ACA provides to millions of Americans on a daily basis. Without it, millions more would lose their coverage.

It is important to remember that the ACA’s constitutionality is currently in litigation once more before the Supreme Court. The Trump administration has taken a virtually unprecedented step and refused to defend it. It has also argued that if any of the law is struck down, it should fall in its entirety. Of course, should this occur, the implications for the U.S. could be dramatic. On the other hand, should former Vice President Joe Biden come to office with a large Democratic majority in both chambers, it seems realistic to expect him to move forward with expanding the ACA and seeking the inclusion of the so-called public option.

Psychedelic Experience? How the Coronavirus Pandemic Disrupts Our Brains Psychedelics can help reset the brain, shaking it out of old patterns. Our current state of uncertainty could have similar impacts on the brain. by Ron Shore

The COVID-19 pandemic has resulted in the widespread disruption of our usual routines. The ambiguity of when it will end, how things will unfold and what will happen in the future has resulted in a collective liminal state, a kind of a waiting area on the threshold of change. 

COVID-19 has undermined our usual expectations and assumptions. Evidence from my work on how our brains react to psychedelics tell me the transient anxiety — which occurs when expectations collapse — may yield benefits. To gain the benefits, we must be intentional in the viewing of this era as a transformational opportunity.

I have looked at how medium-to-high doses of psychedelics can help reset the brain, shaking it out of old patterns. I wonder if our current state of uncertainty could have similar impacts on the brain — a metaphorical psychedelic dose — for new insights, values clarification and a collective reset.

The brain is a prediction machine

A recent study shows experiences with psychedelics such as psilocybin (also known as magic mushrooms) can have disruptive impacts on our brains. Neuroimaging of the brain on psychedelics have revealed a state of chaos, or entropy and a loss of synchronization of brain waves.

Entropy is a measure of uncertainty and randomness or disorder. British neuroscientist Karl Friston defines entropy as a measure of uncertainty, the “average surprise.” Low entropy means, on average, that outcomes are relatively predictable.

In Friston’s view, the brain is a prediction machine. We construct the future from the past. We make predictive inferences (conscious and unconscious) to conserve energy and simplify the interpretation of a continuous input of stimuli.

We gain mastery, but at the expense of novelty.

Disrupting the patterns

Poor mental health often revolves around excessive rumination and repetition. Rumination is rigid, repetitive and negative thinking characterized by low entropy.

In 1949, McGill University psychologist Donald Hebb predicted much of what modern neuroscience would go on to prove with neuroimaging technologies. Hebbs’ postulate — that the neurons that fire together, wire together — provides a summary of the way synaptic pathways bond and are reinforced by repetition.

This repetition and rumination robs the mind of flexibility, especially when attached to memories with heightened (positive or negative) emotional resonance. Repetition-habituated brains marinate in a soup of low novelty and lack of surprise, forecasting tomorrow to be much the same as today.

Psychedelics disrupt our repetitive or ruminative ways of thinking and rewire brain communication patterns. The result is often an altered state of consciousness marked by transient confusion, followed by a high probability of novel, meaningful and possibly even mystical experiences.

When the rigid, top-down control of the ego is loosened, the anarchy of the creative unconscious blooms.

How psychedelics can help

Our research group at Queen’s University recently completed a review of existing studies on psilocybin-assisted therapy. From over 2,000 records, we found nine completed clinical trials with a total of 169 participants.

Overall, the trials showed that most subjects safely tolerated these interventions and showed improved mental health. However, some experienced transient distress and post-treatment headaches. The trend suggests positive outcomes in various conditions such as obsessive-compulsive disorder, addiction, depression, psychological distress associated with life-threatening cancers and demoralization among long-term AIDS survivors.

In short, although psychedelics can be accompanied by known adverse experiences, trials seem to indicate that psilocybin is relatively safe (with the right supports and in a supportive setting) and has a marked ability to interrupt psychopathologies.

To ensure safety and support, the majority of psilocybin trials used the PSI model (preparation, session, integration) with multiple moderate-to-high-doses sessions happening in the company of trained therapists.

Participants report experiences of transient anxiety, distress and confusion, states of joy, interconnectedness, catharsis, forgiveness and wisdom experiences. In contrast to talk therapy, psychedelic sessions are experiential, meaning that we experience changed ways of both seeing and being in the world.

Being OK with uncertainty

Mystical experiences have been reported both by clinical trial subjects and by recreational psilocybin users. Mysticism can be thought of as an experience of absorption, a dissolution of separateness and a sense of deep connection. Absorption is the opposite of rumination.

Rumination carries you away on an eddy of self-referential and self-containing thoughts, while when experiencing absorption, you leave behind your narrow sense of self, experiencing something greater that is both inside and outside of you.

The psychedelic experience is a classic hero’s journey. The hero leaves the comforts of home, faces disruption and challenges to their previous way of thinking and being, has profound and transformative experiences, and returns a changed person.

Leaving predictability and entering into uncertainty is a threshold to transformation.

When predictions fail, opportunities are born

In one study, psilocybin trial subjects reported feeling more deeply connected, open and relational as a result of their entropic, and often difficult, psychedelic experiences. In another study, they have been found to hold less authoritarian political views and be more in touch with nature.

Participants in collective psychedelic rituals commonly experience feelings of deep bond, kinship and even telepathy with other participants. I believe we may be in a similar moment during COVID-19.

COVID-19 has disrupted the normative habits of society. It has forced the economic machine to pause. It has forced many to reevaluate practices and priorities. In some cases, I believe it is dissolving our normal sense of human separateness (even though we are physically distanced).

Perhaps, like the liminal psychedelic state, the uncertainty in which we find ourselves in this moment will lead to more visions of what can be.

The future does not have to remain in the past.

Those of us with the luxury of space and time have an opportunity to reset, unbind our minds, quit repeating old patterns, experience anew what life can hold and to do better.

Coronavirus is Here to Stay: How to Keep your Family Safe There is still so much we scientists and physicians don’t know about the new coronavirus. by Ryan Malosh

Now that states are relaxing social distancing restrictions, people desperately want to see friends and family, go to a restaurant and let our kids have play dates. Even grocery shopping sounds fun. But how can you do that and still stay safe? Here, an epidemiologist who is immune-compromised himself, walks you through some decision making. 

The Centers for Disease Control and Prevention (CDC) has finally released new guidelines for businesses, bars and schools that are considering reopening. Although following these guidelines should help, it’s frustrating there hasn’t been more clear, concise communication about the risk of infection. And without strict guidelines, it will be up to us to minimize our own risk and the risk of everyone around us.

In large part, this is because there is still so much we scientists and physicians don’t know about the new coronavirus. The pace of new research on the virus, SARS-CoV-2, and the disease it causes, COVID-19, is truly astonishing. There are also times when the science and the necessity of the moment are in conflict; a prime example is the confusion about using face masks while a worldwide shortage of personal protective equipment exists.

And the pattern of disease is extremely localized. Michigan’s outbreak looks different from Iowa’s, which looks different from Colorado’s. Even within states, outbreaks are very distinct. The outbreak I’m experiencing in southeast Michigan is not like the one my grandparents are experiencing two hours north of here. As a research scientist, I study herd immunity and vaccine effectiveness. As we slowly begin to return to normal life – albeit a new normal – I can tell you there are ways we can minimize our risk.

As a survivor of leukemia and a bone marrow transplant, I am part of a high-risk population, so my risk calculation is likely different from yours. As my state starts to relax restrictions, I will continue to limit my interactions with others as much as I can. Here are things you can consider.

What’s associated with a high risk of transmission?

How SARS-CoV-2 transmits from person to person is still a mystery. It can certainly be transmitted by large respiratory droplets, like those produced when we cough or sneeze. Evidence also suggests that smaller aerosol particles, spread while talking or breathing, can lead to transmission. There is some evidence that people can transmit the virus before they have symptoms, although they will likely have the highest amount of virus close to the start of the illness.

Taking all this together, it’s safe to say the riskiest thing you can do is to come into close contact with sick people. That’s why the advice about self-isolation if you feel ill is so important.

It’s also becoming clear the virus transmits most effectively in indoor settings. There, close contact between infected people and inadequate ventilation are more likely. The infection risk is especially high among household contacts. Efficient transmission in crowded, enclosed spaces also explains the high attack rates in nursing homes, food processing plants, jails and prisons and cruise ships. On the flip side, the risk of transmission does seem to be lower outdoors.

How do we minimize risk?

If the riskiest thing is to be in a crowd while indoors with sick people, then it follows the least risky behavior is to be in small groups, outdoors and to avoid sick people.

I think it will help to describe a simple model of infectious disease. The rate of new infections over a given time period is called the “force of infection,” which depends on a few things: the rate at which people contact each other; the probability of infection given contact; and the number of infectious individuals in a population.

This means our ability to prevent new infections depends on two things: reducing the rate at which people contact each other – or reducing the probability of infection given contact.

Reducing the contact rate was the goal of stay-at-home measures. By all accounts, this is still the most effective tool to prevent new infections.

Other non-pharmaceutical interventions, like facemasks and hand-hygiene, reduce the effective contact, or the chance the virus is transmitted if there is contact. Universal masking may be particularly effective if we can’t rely on symptomatic screening for identifying infectious cases.

Or maybe you’ve heard of the layers of swiss cheese. Sometimes you have a few interventions (slices of Swiss cheese), but none are perfect (the holes). But stack the slices up, and the holes start to cover up. Layering imperfect interventions can, in a similar way, slow down transmission.

So what does it all mean?

I once read a quote about the common cold from Ian Mackay, an Australian virologist: “The only fail-safe means of avoiding a cold is to live in complete isolation from the rest of humanity.” The same is probably true for COVID-19.

But that’s not realistic. Authorities should borrow ideas from HIV prevention, and focus on clear messages for harm reduction. In the absence of stay-at-home orders, all of us will have to decide for ourselves how much risk we are willing to tolerate.

I’m a leukemia survivor, so I will factor that in. You, too, will need to consider your medical history. When I’m not in isolation, I will stack as many layers of swiss cheese as I can to minimize any risk: staying 6-10 feet away from others, wearing masks, staying outdoors.

I think these are generally common sense guidelines for anyone.

• If your local authorities allow small gatherings, then getting together with friends who aren’t sick or who haven’t been in contact with other sick people is safest outdoors.

• Try to stay as far apart from each other as you can.

• Keep a mask and hand sanitizer nearby.

• Don’t share food or drinks.

• If anyone feels sick or has had recent contact with someone who feels sick they should skip the playdate (this goes for adults and kids).

• If you are seeing someone at high risk of severe disease, an older relative or someone with a compromised immune system, take even more precautions and consider whether you can connect with them virtually.