June 11, 2020

This week we are faced with two issues. Racism that has harmed Black people physically, economically and spiritually for generations has triggered massive protests in cities and towns around the world. The powerful voices of the people are demanding that institutions act now to excise racist practices. Meanwhile, the COVID-19 pandemic continues to spread, especially under the some of the very same crowded conditions that occur during protests.

So, there is the truth about the damage caused by unaddressed racism, but also the consequences of participating in large-scale gatherings in protest of racism, namely, the risk of exposure to COVID-19.

The Truth

There is systemic racism across the U.S. and around the globe. Following the death of George Floyd at the hands of police, the Black Lives Matter movement has triggered collective global outrage. Despite disturbing rhetoric, lies and dystopian messages from Washington, change appears to be occurring at state, city and local levels in America and abroad. There is hope that current heavily militarized policing will shift to public safety concerns, and the deep, underlying health disparities experienced by Black people worldwide will begin to be addressed. A June 10 strike by academics and scientific organizations around the world called attention to the need to take action on systemic inequalities in science.

The COVID-19 pandemic has laid bare how discrimination drives health disparities among Black people. A recent New York Times editorial asks and answers the question “Who Is Most Likely to Die From the Coronavirus?” The top risk factors are all more prevalent in Black people, including hypertension, diabetes, obesity, and chronic lung and kidney diseases. There is just no doubt about the racial inequities.

The Consequences

Massive protests increase the risks of COVID-19 spreading wildly in the community. Protesters are clearly aware and not deterred. The opportunity for meaningful change cannot be missed. But the consequences must be dealt with using science-based approaches in a practical, stepwise fashion. 

Science tells us that a vast number of unexposed individuals are still at risk of new COVID-19 infection. Data from the Wuhan region of China (the original epicenter of the pandemic) indicate that only 3% or so of individuals in that community have antibody levels indicating infection has occurred. This means that the remaining 97% have not yet been infected and are at risk of becoming actively infected and spreading the infection to others, such as those at a higher risk.
 
A large new study indicates that shutdowns may have prevented as many as 60 million people from developing COVID-19. While tremendous for flattening the curve, this also means that so, so many more people now remain at risk for new infection and can contribute to new community spread.
The reality is that COVID-19 will be widespread in our communities for some time. But we cannot live like hermits for the foreseeable future. So, what are practical steps that can be taken by the 97% of people not yet infected to balance the risks of venturing out into the community?
Science-based recommendations for next steps

In a recent survey, 511 experts on epidemiology and infectious diseases answered a range of questions about risks of COVID-19 exposure posed by various activities. The answers are quite revealing:

• Risky activities
  • Most of those surveyed agreed that attending large sporting events, concerts and plays, and the like, will be the most dangerous for a year or more. 
  • Attending weddings and funerals, and routine handshakes or hugs are all in this same risk category. 
  • Working in a shared indoor office space is still considered undesirable. Visiting malls or gyms are additional activities not endorsed by this group. 
  • Traveling by plane is still viewed with a lot of skepticism, although with strict precautions (including masks), this is most likely a lot safer than going to an indoor arena for a sporting event.
• Safer activities
  • Socializing outdoors (for example, dinner in the garden) with a small number of known family or friends. 
  • Going to a carefully set-up restaurant with patio space or excellent physical distancing and ventilation can be considered. This requires detailed precautions (servers with masks or shields, temperature checks, etc.). 
  • Hiking or having a picnic outdoors is also viewed quite favorably by the epidemiologists.
  • Non-urgent medical appointments—again, with detailed precautions.
  • Visiting hair salons received a mixed response, with many indicating it is relatively safe with masks and other safety measures in place (and, close to essential for most of us at some point!).
  • Sequentially, a range of other kinds of activities can be considered in the coming months, including retail activities in your local community (things you really need to do, like get your car repaired, go to the bank or dry cleaners, etc.). Protections are being set up in all these businesses with physical distancing, use of masks and hand-sanitizer. 

Masks

A new study by Britain’s Cambridge and Greenwich Universities emphasizes the major value of wearing a mask in public. The study suggests that the routine use of masks can prevent second waves of COVID-19. The researchers’ key point is that masks limit COVID-19 spread from potential asymptomatic super spreaders, which is the big concern right now after the massive protests. This is very encouraging news

The use of masks is widely attributed to the lesser of impact COVID-19 throughout Asia and elsewhere. Strict protections have had beneficial effects in places such as British Columbia, where friendly approaches to lockdown and the enforcement of simple measures have contained the pandemic. 

Riding in Elevators

Experts advise those who must take elevators to:

• Wear a mask
• Resist touching buttons or surfaces directly
• Use hand sanitizer frequently
• Go at quiet times and even alone, if possible
• Use toothpicks to press buttons

There is no question that elevator rides will be challenging in busy high-rise buildings, despite many new innovations and protections being introduced as rapidly as possible.

Risk Groups

Perhaps the simplest way to guide your decisions in the coming weeks is to pay close attention to the known risk factors. The more risk factors present, the greater the cautions should be. 

• Age is still a key factor, especially for those in their 70s, 80s, 90s or above, with risks clearly increasing with increasing age.
• The added presence of hypertension, diabetes, obesity, chronic lung or kidney disease confer an added level of risk.
• Living in any type of group setting is a definite risk and should be either managed carefully or avoided. In many places, over 50% of deaths have occurred in group settings.
• Underlying genetic factors are still being studied. A recent study indicates correlations with ABO blood groups. A higher risk is linked to blood group Type A-positive and a protective effect for blood group Type O-positive. It appears that the blood group genetic locus can have a positive or negative effect upon activating the ACE2 (angiotensin-converting enzyme 2) surface receptor, which the COVID-10 virus binds to when entering and infecting cells. This can be an opportunity for new targeted therapy. 
• Obviously, having myeloma is a risk factor, especially if the disease has been recently active, requiring induction or re-induction therapy, or ASCT (autologous stem-cell transplant).  Stable disease on maintenance therapy appears to be a much lesser risk. Also, the presence of MGUS (monoclonal gammopathy of undermined significance) does not seem to confer a special risk. (I discuss myeloma and COVID-19 with Dr. Suzanne Lentzsch of the New York-Presbyterian Hospital, and IMF Board Member and myeloma patient Yelak Biru in this podcast.)

The Bottom Line

Individuals with more limited risk (for example, elderly, but with no medical risk factors, living independently) and possibly those whose blood group is Type O-positive can consider expanding social activities more rapidly than those in higher risk categories.

The Way Forward

Facing the truth and consequences head on is the only way to make progress. The good news is that there is a sense that real change is possible and that with better scientific and practical focus we can manage potential surges of COVID-19. Wearing a mask in public is very important. The key in the coming months will be to stay safe and sane with the new normal (or abnormal), which will continue to limit the social contacts that are so much a part of who we are. I hope the suggestions I have given will ease the way forward to steadily expand social and community activities.

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