Covid Prevention: City Versus Country

I was talking with a friend yesterday about her cousin from Wyoming who simply cannot see why he should be wearing a mask, or why we have shut down our world. My sisters and I were discussing when it will be appropriate for us to visit our larger family in Maine, where lobster fishing and tourism have been destroyed by coronavirus shutdowns. In Wyoming, as in Maine, there have been very few cases of Covid.

My friend and I agreed that living here in Massachusetts near Boston is very different. For us, the deaths, the risk, and the way we’re mostly reacting here makes Covid very real and immediate. Perhaps some of our response has a left-leaning tinge, but I really do think it’s more about living in a densely populated place. We are also close to New York City. Even here, a lot of people have died. Covid is very real here.

Covid is real in Maine and Wyoming too, but they are rural and far less dense or populous even in their larger cities. Covid is not immediate and it’s still invisible. It’s just waiting. Wyoming has had 12 deaths. Maine, less than 100. Looked at from this angle, Covid really is like the flu in these and other similar places. The idea that you would need to stop all business and do all the other things we have done seems absurd. Lobstermen have had their entire worldwide market shut down since there are no restaurants open. All for 100 old people who died?

Of course we could say that it was the restrictions on movement and interactions that have kept the virus in check in these rural places. Chances are this plays into the numbers, but mostly, the virus is just going to have a harder time getting a foothold when there are so few people living in less dense settings. Of course no one wants to get the virus, nor die from it, but it’s a trade off similar to the one we make every time we drive a car — there’s risk, but it’s very low. Or at least it’s low now.

So, I get it when people living in less affected parts of the country are frustrated and angry. It really is a city versus country problem at the moment.

However, nearly every study I have read says that Covid spread is just a matter of time, or any other disease that transmits as Covid does. Like the flu. Except that death rates from the flu are far less. Remember, the flu does happen in Maine and Wyoming.

Another major factor is that during this shutdown, we have learned and are still learning what we need to know to manage it. When Covid ripped through Italy in February and March, death rates were 15% and it was absolutely not clear who was vulnerable. We didn’t know how it was transmitted or even how transmissible it was. All we knew was that it was a major shit show and coming fast for us. Now we have a much, much better handle on these characteristics. So in many ways now is the right time to be relaxing restrictions.

Now we know that all people can get it, but mostly older and compromised people suffer the worst outcomes or death. We know an infected person can spread the virus before they have symptoms. We think the majority of transmissions are airborne, and sneezing, coughing, and talking all create droplets. We think viral load and time exposed increase likelihood of infection, so inside and close is bad. We know social distancing and masks can dramatically reduce spread. Little or none of these factors were known in March.

We now also have begun to ramp up testing, and are far more prepared in hospitals.

It may well have been reasonable to relax restrictions in Maine and Wyoming sooner. There are really two things we need to consider in such decisions. First, we need to make sure we avoid bringing the virus into these states or spreading it when it arrives. Second, we need to be sure we are ready to handle cases as they arise.

What doesn’t seem to be clear to many people is that this is a social problem, not an individual one. Perhaps the best way of putting it is that by failing to observe the rules as we understand them now, you’re putting someone’s grandmother at risk. As more data is understood, it’s looking like face coverings are essential in any real social context. The six-foot rule is very important, but there are a lot of cases where that’s hard. A face covering augments distancing measures, but has another important purpose: it’s a signal.

Sadly, lead by Trump, mask wearing has now been linked to manliness, individualism, political leanings, and bravado. It also doesn’t help that it’s hard to find or buy the most effective and comfortable masks, or that they are inconvenient, and can be hot. Or that they interfere with conversation, and in today’s not-quite-normalized-yet world, masks look weird.

But here in Massachusetts where we have seen the devastation from covid, both in deaths and economics, masks are normal and expected.

Indeed here, I believe many of us see failure to wear a mask in public as a sign of disrespect — you are failing as a member of our society to assure the least damaging outcomes, and that is selfish and ignorant. More bluntly, you’re stupid if you don’t wear a face covering.

Yet even here in Massachusetts the directives about masks are a little fuzzy. We are now required to wear them in stores, so that’s good. But outside you should wear them if you’re not able to maintain a six foot separation. But how that works in practice is unclear. Does it matter if I am outside and get close to someone for a few seconds? (Maybe). Does it only matter if I cough or sneeze? (No). Do I need to wear one if I don’t feel sick? (Yes). Will it help me from getting sick? (No).

Above all, masks as a social signal remind us all that we’re very literally in this together. And when all of us are doing something, it really helps if all of us do it all the time. Indeed as China dealt with SARS, they realized that compliance was a) very important to reduction of spread, and b) far more effective when the rule was simply “wear a mask”.

Mask usage, then, is probably the single thing we can all do that is reasonable, effective, and doesn’t cost much. As we now know, this particular virus spreads largely by airborne means, and masks reduce this spread a lot.

The other thing we need to do is be prepared for when the virus does gain a foothold. There have been recent reports of two nail salon employees who were symptomatic with covid yet still saw clients (which is hard to understand at some level), around 50 in both cases. Both the employees and clients were wearing masks, so these cases could indeed help encourage mask use if it turns out that none or few of the exposed clients got sick.

In each of these cases officials made another important step: contact tracing. However, all they did was tell the clients that they may have been exposed. At some level, the clients are also idiots for having close contact with people who were coughing and sneezing. So will they be any smarter when it comes to their behavior for the next few weeks while they may be infected but have no symptoms?

The ideal protocol for contact tracing involves quarantine for anyone exposed to an infected person. China set up special locations for people in quarantine. Here in the Land of the Free, Home of the Brave we don’t take kindly to being told what to do, especially when it involves loss of freedom and money. So will those nail salon patrons follow any protocol, or will they go to the family picnic and infect grandma?

As other retail and business locations open, we’ll have more cases where an infected person comes in contact with multiple other people. Cases will occur, even in Wyoming and Maine. They’ll be far more likely if people ignore social distancing and don’t wear face coverings.

And that’s where Wyoming and Maine face the greatest risks. With the help of politicized messaging about masks and the virus in general, people from less urban locations have the opposite idea of what’s needed. What took days or weeks in NYC will slow-burn its way across rural areas. Greater mobility, including mobility from other states will introduce the virus. Lack of compliance with rules will result in pockets of outbreaks.

At some point, it seems likely that most places will calibrate their responses to the actual threat. A lot of people will die as we get there. By fall, we’ll all be wearing masks. And today’s grim milestone of 100,000 dead may look quaint.

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