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Editor's Comment
COVID-19

Social Distancing—What Would It Mean for It to Work?

  • 1Deputy Editor, JAMA Health Forum
  • 2Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee

The novel coronavirus COVID-19 is the subject of global fascination and fear. It is driving us to maintain social distance from each other while representing an historic experience that will be shared by most of the people alive on the planet in 2020. What we remember about the experience, however, will be shaped by the social context in which we live—and, in turn, that social context will shape the path of the disease through our communities.

Gostin and Wiley recently wrote in JAMA about the public health powers governments have to close schools and businesses, restrict travel, and impose stay-at-home orders.1 These powers are now being summed up under the term “social distancing,” but they are being implemented differently across the US and around the world. The Kaiser Family Foundation is tracking the social distancing actions taken in different US states. They range from limitations on large gatherings to stay-at-home policies to quarantines for travelers. Some states have backed actions with enforcement or extensive public messaging, while others have chosen a less active stance. Internationally, the range of social distancing policies has been larger and has included lockdowns and cell phone tracking of those near infected individuals. These measures have reflected not only the extent of the disease but also the ability and willingness of leaders to implement these measures within their jurisdictions.

All of this had led to discussions about the ideal set of actions governments should take—and about the expected effects of such actions. But it is hard to apply a single set of best policies to all areas. For example, for people who live in a rural area and already shop for essentials on a biweekly basis, policies that limit travel to essential shopping may reduce contacts very little. Similarly, young people living in urban areas and regularly attending events might experience a significant reduction in the number of contacts simply with a ban on larger gatherings.

This wide variation in policies—and in the effects of policies depending on the underlying social structure of a group or area—is a huge challenge for those trying to model the course of the pandemic so that leaders can prepare accordingly. The widely publicized model by Ferguson et al of Imperial College London made assumptions about the imposition and effects of population-wide social distancing and how long it would be maintained; the Institute for Health Metrics and Evaluation model out of the University of Washington assumes that the timing of the peak number of cases after strict social distancing, like that imposed in China, Northern Italy, and Spain, will be followed in other places that implement a variety of social distancing policies. Still other modelers are using different assumptions about how social distancing policies might limit the spread of the virus.

Gostin and Wiley, in summing up how to balance health and human rights, appeal to the use of evidence to find the most justifiable path. They write that “although there is no clear answer, there are guideposts: adopt rigorous scientific standards based on the best available evidence, make decisions transparently and fairly, and adopt the least restrictive measures needed to protect the public’s health.”1 That is certainly the correct route, and yet such evidence is, thus far, lacking in sufficient detail to guide policy at the local level.

Some limited evidence is emerging from China, where provinces outside of Hubei implemented lockdowns, promulgated widespread testing, and are assiduously tracing the origins of new cases and any contacts who may be infected. This research and modeling makes clear that while such practices can drive down transmission of the virus, relaxing social distancing and reopening businesses, even with testing and contact tracing in place, can lead to rebounds in infection that might require still more stringent social distancing to reverse.2 Thus, we need more evidence generated and further modeling to inform decision-makers about how best to ease social distancing without risking a yet more costly rebound.

References
1.
Gostin  LO, Wiley  LF.  Governmental public health powers during the COVID-19 pandemic: stay-at-home orders, business closures, and travel restrictions.   JAMA. Published online April 2, 2020. doi:10.1001/jama.2020.5460PubMedGoogle Scholar
2.
Leung  K, Wu  JT, Liu  D, Leung  GM.  First-wave COVID-19 transmissibility and severity in China outside Hubei after control measures, and second-wave scenario planning: a modelling impact assessment.   Lancet. Published online April 8, 2020. doi:10.1016/S0140-6736(20)30746-7PubMedGoogle Scholar
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