Pushkin from Pushkin Industries. This is Deep Background, the show where we explore the stories behind the stories in the news. I'm Noah Feldman. The official start of summer is this Saturday. But what kind of summer will this be? Will we and our families be able to interact with others? Can we have a backdoor barbecue under social distancing? Can we go to a public pool? Can we go anywhere? What are the range of risks that it's rational to undertake in the middle of a pandemic. Here to help us work through these questions is doctor Julia Marcus. She's an infectious disease epidemiologist and an assistant professor at the Harvard Medical School in the Department of Population Medicine. She has been a forthright, clear, analytic voice trying to explain in practice what we can and cannot do and what our risks look like, specifically from the perspective of an expert who spends most of her non pandemic time thinking about public health and its relationship to HIV AIDS. For doctor Marcus, the central question we need to confront is how can you have a life in the pandemic? Julia, thank you very much for joining me. The crucial issue that I'm focused on, and I don't think I'm unique in this regard, is the fact that school is ending such as it was, and there is going to be tremendous pressure on all of us to come up with a game plan for the summer, including a game plan where our children are not in house lockdown for the entire summer. So I want to start by just asking you for your headlines about what we should be trying to do rationally going forward with our kids. Maybe I'll start by just tacking about the way that I'm thinking about this overall and what I've been writing about. So back in early May, I started thinking about how we were framing our public health messaging. And for the first few months in March in April, our public health messaging was really absolutist because it needed to be. It was just stay home only, go out for essential activities like going to the grocery store or the pharmacy, and other than that, stay home. And during that time a couple things happened. One is that our understanding of viral transmission evolved, so we started to learn more about places that were higher risk for transmission and places that were lower risk, and we also realized that we're going to be doing this for a lot longer than we had hoped. If you think back to early March, I think we all really hoped this was going to be like a couple weeks and then we'll go back to our lives, and that's not at all how things played out. And now we're starting to think about how we can adapt to live with this virus for a very long time, months, maybe even years, until we have an effective vaccine that can be scaled up. So now the question is how can we live our lives in a way that's sustainable while still keeping the risk of transmission low. And so what I proposed was rather than this abstinence only messaging which says have no social contact unless it's absolutely essential, just abstain. You know, we know that that's not going to be sustainable for everyone for the long term. So what if we approach this from a harm reduction perspective where we accept that some risks need to happen for various reasons, often for reasons that are out of people's control, and give people the guidance they need to be as safe as possible when they do take those risks, and we can think about how this approach has been used successfully in other areas of public health, like safer sex education is a key one and one that's close to my heart as an HIV researcher. Actually a harm reduction was developed for and also with collaboration with people who use drugs. That's kind of the core approach to reducing the potential harms of substance use. So now I think that that's how we should be thinking when we think about, you know, what are we going to do this summer? How are we going to keep our kids stimulated and happy and as parents stay sane. I think we need to think from this approach of sustainability while trying to keep our risk and others risk low. That I think is an incredibly helpful set of frameworks, and if you don't mind, I'd like to dig into each of them a little bit before we get to the concrete recommendations. One is this idea that we need to be able to sustain this for a longish period of time, and there I'm struck that there seems to be one major unknown, and that is the question of are we going to reach a point where we more or less at a measured pace, all to get or sixty or seventy percent of us have to actually be exposed to stars Cove two. If we thought that the two vaccines that are nearing human testing had a reasonable shot of succeeding, and we thought that maybe a year from now we would be in a position to actually have enough dosis of that vaccine to reach many people in the United States and perhaps in the world, then I can sort of imagine saying we should really still be on a plan where our goal is for us and our children and our family members just never to get exposure to this virus at all. But if the probabilities of those vaccines succeeding are lower than some enthusiastic people say, then it really seems crazy to attempt a kind of long term goal of just not getting this because then, you know, the best epidemiological studies that I've read suggest what we just have to do is accept trying not to break the hospitals, but have to basically all accept that we're going to get the virus over time. So how much is the background likelihood that a vaccine might work and be available in the next year affecting your calculus. I kind of go back and forth between the two things you just said. One is, let me just try as hard as I can to keep my family from getting this virus, and let's see what we can do to keep our risk as low as possible and the risk of our loved ones for an extended period of time, and the hopes that not only will there be an effective vaccine in the next let's say year, but also better treatment. There are ways that the landscape could change that would mean that it would be better to get this virus later rather than earlier. And then there are times when I feel sort of fatalistic, and I feel like, if three quarters of us need to get this eventually, why are we as a family, I don't mean as a country, but why is my family trying so hard to keep our risk low? But what you're talking about, I want to make a distinction between individual decision making around risk and what informs decision making versus what we, as a national public health body should be doing to approach this. And I don't support an approach from a national perspective of just saying, you know what, three quarters of us have to get this anyway, let's just reopen and let that happen. And that's the herd immunity approach, which I think has been roundly criticized in general by public health experts for leading to unnecessary and egregious amount of death and also being just an unethical approach to a public health strategy. I want to also go back to a point you kind of mentioned in passing about not breaking our hospitals. That's a very important point to be considering. And when we look at places that have reopened on the earlier end and are now approaching an emerge and situation already just a few weeks later, that really calls into question of what would happen if we just said, you know, what we're doing is not sustainable. We're all going to get this anyway, let's just reopen. I think we have to have an intelligent approach to life right now that doesn't look like business as usual simply because we will break our healthcare system if we do go back to business as usual. For other reasons as well, but that one, I think is a crucial one that we have to acknowledge. The other part of your framework that I really want to ask you about is the part that has to do with what you do every day when there isn't a COVID nineteen epidemic going on, and that is HIV prevention. And you gave two analogies sex and drugs to the question of sustainability and prevention. Those are really important cases and in certain respects different cases, but they both raise this issue of sustainability. How much can the human being, with a human being is now full desires and drives, actually go forth in an extreme absinate state of play. So would you say a little bit more about the philosophy according to which at some point we have to say, well, you know, some people are going to have sex, and some of that sex is going to be risky and we have to be realistic about that, and some of the that some people are going to have drug dependencies and are going to take drugs whether we like it or not, because we don't have perfect solutions to those problems. Yeah, the analogy that I made was thinking back to the early days of AIDS, when we didn't have a name for HIV. We knew there was this scary virus that was killing gay men, and the public health advice that gay men were getting was to just stop having sex that obviously was not going to be a sustainable approach for everyone or possibly anyone. So what gay men did as a community was several gay men came together with a physician expert and they came up with a guide to having sex in an epidemic. That was really the first kind of foundational safer sex approach to HIV. And that's essentially what we need to be doing right now is acknowledging that we cannot abstain from social contact indefinitely. It's just not possible. So the next best thing is figuring out the equivalent of safer sex for COVID, which is well, in some cases, it actually is about sexual contact. How can we help people have safer sexual contact, but more broadly, how can we help people have safer social contact that gives them enough to fulfill their human needs such that they can actually forego some of the really high risk things we want to avoid, like let's say a crowded dinner party. So if you give someone guidance around lower risk social contact, can you actually help them avoid those high risk situations that could become super spreader events? And if you can, then that's a public health win. But I think there are a lot of reasons why this country is is hesitant to take that HERM reduction approach and tends to be more absolutist in its public health messaging and just tell people here's the safest thing you can do, which is to stay home. There's something really profound about what you're saying to me, namely that human beings have a basic instinct to sociality. We have a basic need to be social. We are social beings in the same way that we need other forms of human contact. So if that's the case, I think what I hear you saying is that we need a model. Just like people at the beginning of the HIV AIDS crisis came up with a guide to sex in the pandemic, we need to start building a guide to socializing in the pandemic. Am I reading you right? Is that in fact analogy that you're offering. Yeah? Absolutely, that is exactly what I think we need. Is kind of the corollary to that manual on how to have sex in an epidemic. We need a manual on how to have a life in a pandemic. We'll be back in a moment. I'm gonna start by asking you to begin to fill in some of the elements of your model of how we can have a life in the pandemic. Eventually, I'm going to ask you about some of the details about including how to have sex in the pandemic, but let's start with how to have a life in the pandemic first. Yeah, So, I think what we need, and what we're just starting to see is public health guidelines that move beyond that absolutest message of just stay home, stay six feet apart, wash your hands, wear a mask, and instead of just telling people here's the safest thing you can do, start to tell people the next safest thing and the next safest thing, so that they get a sense of a spectrum of risk. There's a lot in between staying home by yourself and with your household members and having a crowded indoor dinner party. There's a lot of gray area. Risk is not binary. It's not that we stay home and we're safe, and then we walk out our front door and we're infected. So once you give people a sense of that spectrum of risk, then they can start to think about where they can place themselves on that spectrum of risk that will keep them as low risk as possible, but allow them to live their lives in a sustainable way. And if we don't do that, if we go back to that abstinence only messaging example, let's say we tell people just don't have sex. Inevitably, some people will have sex, and if we don't give them any information about how to reduce any potential harms if they do have sex, then we've missed an opportunity as a public health field. So we think if we think about teenagers who go and have sex and haven't heard anything about condoms or STIs or how to prevent pregnancy, then we've missed an opportunity there. And that's why abstinence only messaging is associated with worse health outcomes than safer sex education, and so the same applies here. We need to provide people with a sense of that spectrum of risk so that they can make more informed decisions when they inevitably, in some cases do take some risks. What does advice along that spectrum of risk concretely look like, Because there's more uncertainty here than there is, for example, in the case of ten sex. I mean, we don't necessarily understand fully all the mechanisms of transmission, So what does the spectrum practically look like to you? So, on a very simple level, and this is something that I put together in an infographic a few weeks ago, we can think about almost like a stop light sort of framework, where on the green end of things, the lowest risk end, you're at home, you're either alone or you're with your household members. And then maybe slightly closer to the yellow taking a little bit of risk but still fairly low risk, is just being outdoors. We know that the risk of transmission is lower outdoors than indoors, and you can think of different activities you can do outdoors with other people that are still fairly low risk, like going for a walk, going for a bike ride with somebody. In those cases you can still use other strategies like masks and social distancing to keep risk as low as possible. And then when we think about moving up a little bit toward the full on yellow, maybe even slightly orange end of things, would be having a group gathering outdoors where people are stationary, like a picnic or like an outdoor barbecue, they're talking face to face, the risk starts to go up again. Masks and distancing will minimize risk in that setting as well. And then finally on the red end of things, the highest risk end would be a group gathering indoors in an enclosed setting not well ventilated. And once we have that spectrum of risk, people can start they can apply that to their lives. So if the question is can I see this other family, they can think about that spectrum of risk and think, well, can I go on a walk with them? Can I go on a bike ride with them? Will that satisfy my need for social contact? If it doesn't, okay, what's the next safest thing that will satisfy my need? Is it having a picnic? And then how can I minimize risk in that setting? Masks, distancing, bringing your own food. There may be some other strategies in terms of hand hygiene to keep risk as low as possible. What about kids and play dates doesn't fit so neatly into your continuum because it might just be one kid going off to another family, but then your child has been exposed potentially to that family's risk and therefore comes home and potentially exposes your family. Right, So kids are tricky always, and it'll depend someone on the age of the kid and what the play date looks like not every play date will be created equal in terms of risk, and not every kid, depending on their age, will understand the need for distancing. Some may. In our family, we have a three year old and a six year old, they've actually been surprisingly to adapt to this new norm around distancing. We haven't really tried any play dates with other families, but in cases where they feel like we're getting too close to people, they will police us and say, Mama, you're too close to this person that's less than six feet. So I actually think it may be possible to have a six year old get together with another six year old in a way that's somewhat distant, like going on a bike ride, kicking a soccer ball around in the park, maybe playing ping pong. You know, there are some strategies we could potentially try, And I think it is harder with younger kids who don't understand that need for physical distancing. And also it gets weird where you're hovering over your kids, you're policing them, you're kind of stressing them out. The whole thing just feels sort of pathological and weird. And so is there another strategy. So one strategy that has been recommended in other countries is social bubbles. Can we think about ways to expand our social bubbles include one other family, Let's say that has kids the same age as ours or similar ages, and we just decide not to do any physical distancing from each other, but to keep doing it from other people and to keep that risk communication open in case there is some leak in the bubble and we need to take a break. But this has actually been shown in a recent modeling study to be a potentially very effective way to continue flattening the curve while giving people some social contact that they may need and hopefully helping them forego some of these higher risk situations like going to bars, having crowded dinner parties. That may be one strategy for play dates that's much more realistic than trying to have a play date where you're keeping kids physically apart. The bubble or pod strategy does model really well because the models tend to assume a high percentage of compliance. Now, you can always tweak the models to reduce the compliance and then see what happens. But these models are very respond to the number that you put in because it is just a model for how much people are complying, and the moment just a few people aren't complying, it becomes harder to sustain this kind of idea. So I'm wondering what your instinct is about that. I mean, I know all the recommendations say, will find another family whose values match your family. I mean, the whole thing sounds sort of like you're trying to marry the other family, and within some realistic bounds, you could perhaps do that. But then you imagine your family has a bunch of kids, another family has a bunch of kids. People live in blended families today and complex families where children move from one house to another house. There are just so many different variables that, to my mind at least, make it a little harder to say with great confidence that we can be any perfectly locked in bubble or pod. If you're perfectly locked in the bubble or pod, then sure it doesn't it does not a problem at all. Yeah, I mean, it does depend on compliance. But I think the question is, what is the comparison group here? If we're making a decision about creating a pod with another household, what is the alt tternative approach that we're considering. Is it going back to business as usual and just saying I can't do this anymore. In that case, trying to create a pod will be a lower risk strategy. I think it's always important here to be thinking about what the counterfactual is, what is our alternative approach, and is this strategy potentially keeping us from something that would be much higher risk. The Netherlands, which has a history, at least a modern history of being realistic about sex and drugs, was recommending, actually pretty early in this process, that people should have what they called a sex buddy. Their words funny how people take English words and turn them into their own language, and that that should be people's solution for having a sexual life, not just a social life. More broadly, what's your reaction. I think it's a fantastic harm reduction approach that's really analogous to the social bubbles idea for households the pods. It's basically like a sex pod, where the overall framework is keep your contacts as minimal as possible. You want a few contacts as possibles, both socially and sexually, and the Netherlands had originally said don't have sex with anybody outside of your household, and single people revolted and said that's not fair. Sexual contact is a human need for many of us. So the Netherlands said, okay, here's the lowest risk way to have sexual contact, which is picking one person and sticking with them as long as possible and at least having just one partner at a time. And it's a perfect example of how to approach this with empathy and with the acceptance of the reality of human needs. And I think that's the kind of messaging that we need in the US. But I think the US will be slow to adopt for fear that by saying get a sex buddy, we are promoting risk taking that we want people to actually avoid. Epidemiologists like you wear two hats. One is a hat, which is a normative hat. You know, you tell us what to do to be safe doing that, and I'm grateful. The other is a predictive hat, where you're trying to figure out what the world is going to look like. So let me ask you to put on their predictive hat. I'm curious to know what you really in the real world. I think this is all going to look like at the end of the summer. That's a tough question. I get a bit depressed when I think about what things may look like. I feel like our government nationally has given up, not even that it necessarily was ever trying that hard to respond to this pandemic, but certainly is no longer trying at all. I think some states have also adopted that approach and have essentially given up, and we're now seeing the early results of that, with some very stark increases and cases and hospitalizations, and I think it's very hard to imagine going back to another lockdown in those areas. I think people will not accept it. Even if the state were to try to adopt it, I don't think people will accept it. And so I don't know how this is going to play out, but I think it's not going to be pretty, and it's I find it, actually, as a citizen, kind of heartbreaking. Just to follow the line of that scenario, Let's imagine that in a state like Arizona, the number of cases goes up, the state wants to respond by pushing for greater social distancing or even a lockdown, and the public just won't comply. We get a kind of spontaneous adoption by the public of the idea that we're going for her community. I mean, that is something where the government could in theory, really massively cracked down, But it's very unlikely that would happen given the structure of our democracy. If enough people don't want to comply, we probably won't get compliance. Then we'd have some places in the United States that we're actually adopting a everyone should get it strategy. Other places are very unlikely to go down that road. Does that seem inherently bad to you? You know, in constitutional law, which is what I do is my day job, we sometimes talk about the states as quote laboratories of democracy, which is meant as a metaphor. In this instance, it's not really even a metaphor. I mean, we're talking about the possibility that different states will actually genuinely try completely different things, and if there's a certain degree of isolation between them, maybe we'll just find out which one works better, works better for people's health, works better for the economy. Does that seem to you completely crazy? Well, the very states that are likely to go down the route you just described of refusing to comply with any future lockdown measures and just seeing what happens. Those are the states where we are likely to see the greatest inequities in how this pandemic plays out if we think about states in the South, in particular, where racial inequities and health, for example, are already stark, where the people who are most likely to still be working. I mean this true across the US. The people who are most likely to still be working and be exposed to the virus are people of color and people who are poor and need to be at work. So I would guess that the way that this natural experiment would play out would have some really unjust inequities in terms of who is impacted by the pandemic in ways that we've already seen, but I think will become exacerbated if we take a herd immunity approach. I mean, as you just as you said, we're already seeing that you're already three times more likely to die of COVID nineteen if you're African American. And indeed, I mean one of the things I was going to say about the spectrum of risk and the experiments with pods, all of it assumes a kind of model of what's the ideal thing. The ideal thing is the two parent family in its picket white fenced home, you know, maybe potting with another similar family, the idea being that everyone can afford not to be exposed for financial reasons. And then you know, if well, if she has somebody is single then and they're looking for some human or sexual contact, and you say, wow, monogamy at least would be the next best step. You know, the whole thing follows a kind of continuum towards the more more more normative picture of what we imagine upper middle class or middle class at least left to look like. So, I mean, what you're saying is true. I don't dispute it at all. But aren't don't we already see that those models are kind of dead ends. Yes, I think it's a great point that the assumption that somebody can comfortably pod with another family or have a sex buddy and make these calculated choices around risk, it's based in an assumption that somebody has some level of privilege to be able to do that. And it's abundantly clearer that in general, social distancing and calculated choices around risk are very much a privilege that are not afforded to people who have to return to work. Because the government has not supported them enough to allow them to stay home, and people who live in very crowded housing who can't necessarily distance and then make these controlled decisions around which families they are going to pod with. So I think it's a great point that needs to be acknowledged. I still think the public deserves some understanding of a spectrum of risk, and that everyone can benefit to some extent from learning more about their risk that goes beyond my risk is zero if I'm in my house, and my risk is one if I walk out my front door, which I think has led to a lot of confusion around where risk really lies and has prevented people from making the most informed decisions about their everyday lives and the choices that they've already been making for the last several months. Where can listeners see your infographic with a spectrum of risk? It is posted on Twitter and it has also been adapted by Vox. They put out a much more professional looking version, so I would encourage people to search for that. Julia, thank you so much for this analysis. It's really insightful, very powerful, and I think I and a lot of other people will think about it very very carefully in the weeks and months ahead. Thanks so much for having this is a great conversation. Listening to doctor Julia Marcus, I was deeply struck by a truth that seems to me pretty profound that she was getting at. Human beings have needs. Social life is indeed one of those fundamental human needs. To be social is part of what makes us human. And so says doctor Marcus, we need to have a life in the pandemic, and what we need to do then is to evaluate risk against the backdrop of the reality that we still have an imperative to have a life. Making that determination of how to have a life in the pandemic will be at the level of the individual and of the family. We need to keep in mind that it's a decision that will always be made against the backdrop of what privilege we may in fact have. No matter who you are, though, you still have to undergo some analysis of what the relative risks are that you can and are willing to take. And I, for one, believe we can do that better in the presence of knowledge and understanding than we could without it. Until the next time I speak to you, be careful, be safe, and be well. Deep background is brought to you by Pushkin Industries. Our producer is Lydia Jane Cott, with mastering by Jason Gambrell and Martin Gonzalez. Our showrunner is Sophia mckibbon. Our theme music is composed by Luis GERA special thanks to the Pushkin Brass, Malcolm Gladwell, Jake of Weisberg, and Mia Lobel. I'm Noah Feldman. I also write a regular column for Bloomberg Opinion, which you can find at bloomberg dot com slash Feldman. To discover Bloomberg's original slate of podcasts, go to Bloomberg dot com slash Podcasts. And one last thing. I just wrote a book called The Arab Winter Patrogedy. I would be delighted if you checked it out. If you liked what you heard today, please write a review or tell a friend. You can always let me know what you think on Twitter. My handle is Noah R. Feldman. This is deep background

Pushkin from Pushkin Industries. This is Deep Background, the show where we explore the stories behind the stories in the news. I'm Noah Feldman. The official start of summer is this Saturday. But what kind of summer will this be? Will we and our families be able to interact with others? Can we have a backdoor barbecue under social distancing? Can we go to a public pool? Can we go anywhere? What are the range of risks that it's rational to undertake in the middle of a pandemic. Here to help us work through these questions is doctor Julia Marcus. She's an infectious disease epidemiologist and an assistant professor at the Harvard Medical School in the Department of Population Medicine. She has been a forthright, clear, analytic voice trying to explain in practice what we can and cannot do and what our risks look like, specifically from the perspective of an expert who spends most of her non pandemic time thinking about public health and its relationship to HIV AIDS. For doctor Marcus, the central question we need to confront is how can you have a life in the pandemic? Julia, thank you very much for joining me. The crucial issue that I'm focused on, and I don't think I'm unique in this regard, is the fact that school is ending such as it was, and there is going to be tremendous pressure on all of us to come up with a game plan for the summer, including a game plan where our children are not in house lockdown for the entire summer. So I want to start by just asking you for your headlines about what we should be trying to do rationally going forward with our kids. Maybe I'll start by just tacking about the way that I'm thinking about this overall and what I've been writing about. So back in early May, I started thinking about how we were framing our public health messaging. And for the first few months in March in April, our public health messaging was really absolutist because it needed to be. It was just stay home only, go out for essential activities like going to the grocery store or the pharmacy, and other than that, stay home. And during that time a couple things happened. One is that our understanding of viral transmission evolved, so we started to learn more about places that were higher risk for transmission and places that were lower risk, and we also realized that we're going to be doing this for a lot longer than we had hoped. If you think back to early March, I think we all really hoped this was going to be like a couple weeks and then we'll go back to our lives, and that's not at all how things played out. And now we're starting to think about how we can adapt to live with this virus for a very long time, months, maybe even years, until we have an effective vaccine that can be scaled up. So now the question is how can we live our lives in a way that's sustainable while still keeping the risk of transmission low. And so what I proposed was rather than this abstinence only messaging which says have no social contact unless it's absolutely essential, just abstain. You know, we know that that's not going to be sustainable for everyone for the long term. So what if we approach this from a harm reduction perspective where we accept that some risks need to happen for various reasons, often for reasons that are out of people's control, and give people the guidance they need to be as safe as possible when they do take those risks, and we can think about how this approach has been used successfully in other areas of public health, like safer sex education is a key one and one that's close to my heart as an HIV researcher. Actually a harm reduction was developed for and also with collaboration with people who use drugs. That's kind of the core approach to reducing the potential harms of substance use. So now I think that that's how we should be thinking when we think about, you know, what are we going to do this summer? How are we going to keep our kids stimulated and happy and as parents stay sane. I think we need to think from this approach of sustainability while trying to keep our risk and others risk low. That I think is an incredibly helpful set of frameworks, and if you don't mind, I'd like to dig into each of them a little bit before we get to the concrete recommendations. One is this idea that we need to be able to sustain this for a longish period of time, and there I'm struck that there seems to be one major unknown, and that is the question of are we going to reach a point where we more or less at a measured pace, all to get or sixty or seventy percent of us have to actually be exposed to stars Cove two. If we thought that the two vaccines that are nearing human testing had a reasonable shot of succeeding, and we thought that maybe a year from now we would be in a position to actually have enough dosis of that vaccine to reach many people in the United States and perhaps in the world, then I can sort of imagine saying we should really still be on a plan where our goal is for us and our children and our family members just never to get exposure to this virus at all. But if the probabilities of those vaccines succeeding are lower than some enthusiastic people say, then it really seems crazy to attempt a kind of long term goal of just not getting this because then, you know, the best epidemiological studies that I've read suggest what we just have to do is accept trying not to break the hospitals, but have to basically all accept that we're going to get the virus over time. So how much is the background likelihood that a vaccine might work and be available in the next year affecting your calculus. I kind of go back and forth between the two things you just said. One is, let me just try as hard as I can to keep my family from getting this virus, and let's see what we can do to keep our risk as low as possible and the risk of our loved ones for an extended period of time, and the hopes that not only will there be an effective vaccine in the next let's say year, but also better treatment. There are ways that the landscape could change that would mean that it would be better to get this virus later rather than earlier. And then there are times when I feel sort of fatalistic, and I feel like, if three quarters of us need to get this eventually, why are we as a family, I don't mean as a country, but why is my family trying so hard to keep our risk low? But what you're talking about, I want to make a distinction between individual decision making around risk and what informs decision making versus what we, as a national public health body should be doing to approach this. And I don't support an approach from a national perspective of just saying, you know what, three quarters of us have to get this anyway, let's just reopen and let that happen. And that's the herd immunity approach, which I think has been roundly criticized in general by public health experts for leading to unnecessary and egregious amount of death and also being just an unethical approach to a public health strategy. I want to also go back to a point you kind of mentioned in passing about not breaking our hospitals. That's a very important point to be considering. And when we look at places that have reopened on the earlier end and are now approaching an emerge and situation already just a few weeks later, that really calls into question of what would happen if we just said, you know, what we're doing is not sustainable. We're all going to get this anyway, let's just reopen. I think we have to have an intelligent approach to life right now that doesn't look like business as usual simply because we will break our healthcare system if we do go back to business as usual. For other reasons as well, but that one, I think is a crucial one that we have to acknowledge. The other part of your framework that I really want to ask you about is the part that has to do with what you do every day when there isn't a COVID nineteen epidemic going on, and that is HIV prevention. And you gave two analogies sex and drugs to the question of sustainability and prevention. Those are really important cases and in certain respects different cases, but they both raise this issue of sustainability. How much can the human being, with a human being is now full desires and drives, actually go forth in an extreme absinate state of play. So would you say a little bit more about the philosophy according to which at some point we have to say, well, you know, some people are going to have sex, and some of that sex is going to be risky and we have to be realistic about that, and some of the that some people are going to have drug dependencies and are going to take drugs whether we like it or not, because we don't have perfect solutions to those problems. Yeah, the analogy that I made was thinking back to the early days of AIDS, when we didn't have a name for HIV. We knew there was this scary virus that was killing gay men, and the public health advice that gay men were getting was to just stop having sex that obviously was not going to be a sustainable approach for everyone or possibly anyone. So what gay men did as a community was several gay men came together with a physician expert and they came up with a guide to having sex in an epidemic. That was really the first kind of foundational safer sex approach to HIV. And that's essentially what we need to be doing right now is acknowledging that we cannot abstain from social contact indefinitely. It's just not possible. So the next best thing is figuring out the equivalent of safer sex for COVID, which is well, in some cases, it actually is about sexual contact. How can we help people have safer sexual contact, but more broadly, how can we help people have safer social contact that gives them enough to fulfill their human needs such that they can actually forego some of the really high risk things we want to avoid, like let's say a crowded dinner party. So if you give someone guidance around lower risk social contact, can you actually help them avoid those high risk situations that could become super spreader events? And if you can, then that's a public health win. But I think there are a lot of reasons why this country is is hesitant to take that HERM reduction approach and tends to be more absolutist in its public health messaging and just tell people here's the safest thing you can do, which is to stay home. There's something really profound about what you're saying to me, namely that human beings have a basic instinct to sociality. We have a basic need to be social. We are social beings in the same way that we need other forms of human contact. So if that's the case, I think what I hear you saying is that we need a model. Just like people at the beginning of the HIV AIDS crisis came up with a guide to sex in the pandemic, we need to start building a guide to socializing in the pandemic. Am I reading you right? Is that in fact analogy that you're offering. Yeah? Absolutely, that is exactly what I think we need. Is kind of the corollary to that manual on how to have sex in an epidemic. We need a manual on how to have a life in a pandemic. We'll be back in a moment. I'm gonna start by asking you to begin to fill in some of the elements of your model of how we can have a life in the pandemic. Eventually, I'm going to ask you about some of the details about including how to have sex in the pandemic, but let's start with how to have a life in the pandemic first. Yeah, So, I think what we need, and what we're just starting to see is public health guidelines that move beyond that absolutest message of just stay home, stay six feet apart, wash your hands, wear a mask, and instead of just telling people here's the safest thing you can do, start to tell people the next safest thing and the next safest thing, so that they get a sense of a spectrum of risk. There's a lot in between staying home by yourself and with your household members and having a crowded indoor dinner party. There's a lot of gray area. Risk is not binary. It's not that we stay home and we're safe, and then we walk out our front door and we're infected. So once you give people a sense of that spectrum of risk, then they can start to think about where they can place themselves on that spectrum of risk that will keep them as low risk as possible, but allow them to live their lives in a sustainable way. And if we don't do that, if we go back to that abstinence only messaging example, let's say we tell people just don't have sex. Inevitably, some people will have sex, and if we don't give them any information about how to reduce any potential harms if they do have sex, then we've missed an opportunity as a public health field. So we think if we think about teenagers who go and have sex and haven't heard anything about condoms or STIs or how to prevent pregnancy, then we've missed an opportunity there. And that's why abstinence only messaging is associated with worse health outcomes than safer sex education, and so the same applies here. We need to provide people with a sense of that spectrum of risk so that they can make more informed decisions when they inevitably, in some cases do take some risks. What does advice along that spectrum of risk concretely look like, Because there's more uncertainty here than there is, for example, in the case of ten sex. I mean, we don't necessarily understand fully all the mechanisms of transmission, So what does the spectrum practically look like to you? So, on a very simple level, and this is something that I put together in an infographic a few weeks ago, we can think about almost like a stop light sort of framework, where on the green end of things, the lowest risk end, you're at home, you're either alone or you're with your household members. And then maybe slightly closer to the yellow taking a little bit of risk but still fairly low risk, is just being outdoors. We know that the risk of transmission is lower outdoors than indoors, and you can think of different activities you can do outdoors with other people that are still fairly low risk, like going for a walk, going for a bike ride with somebody. In those cases you can still use other strategies like masks and social distancing to keep risk as low as possible. And then when we think about moving up a little bit toward the full on yellow, maybe even slightly orange end of things, would be having a group gathering outdoors where people are stationary, like a picnic or like an outdoor barbecue, they're talking face to face, the risk starts to go up again. Masks and distancing will minimize risk in that setting as well. And then finally on the red end of things, the highest risk end would be a group gathering indoors in an enclosed setting not well ventilated. And once we have that spectrum of risk, people can start they can apply that to their lives. So if the question is can I see this other family, they can think about that spectrum of risk and think, well, can I go on a walk with them? Can I go on a bike ride with them? Will that satisfy my need for social contact? If it doesn't, okay, what's the next safest thing that will satisfy my need? Is it having a picnic? And then how can I minimize risk in that setting? Masks, distancing, bringing your own food. There may be some other strategies in terms of hand hygiene to keep risk as low as possible. What about kids and play dates doesn't fit so neatly into your continuum because it might just be one kid going off to another family, but then your child has been exposed potentially to that family's risk and therefore comes home and potentially exposes your family. Right, So kids are tricky always, and it'll depend someone on the age of the kid and what the play date looks like not every play date will be created equal in terms of risk, and not every kid, depending on their age, will understand the need for distancing. Some may. In our family, we have a three year old and a six year old, they've actually been surprisingly to adapt to this new norm around distancing. We haven't really tried any play dates with other families, but in cases where they feel like we're getting too close to people, they will police us and say, Mama, you're too close to this person that's less than six feet. So I actually think it may be possible to have a six year old get together with another six year old in a way that's somewhat distant, like going on a bike ride, kicking a soccer ball around in the park, maybe playing ping pong. You know, there are some strategies we could potentially try, And I think it is harder with younger kids who don't understand that need for physical distancing. And also it gets weird where you're hovering over your kids, you're policing them, you're kind of stressing them out. The whole thing just feels sort of pathological and weird. And so is there another strategy. So one strategy that has been recommended in other countries is social bubbles. Can we think about ways to expand our social bubbles include one other family, Let's say that has kids the same age as ours or similar ages, and we just decide not to do any physical distancing from each other, but to keep doing it from other people and to keep that risk communication open in case there is some leak in the bubble and we need to take a break. But this has actually been shown in a recent modeling study to be a potentially very effective way to continue flattening the curve while giving people some social contact that they may need and hopefully helping them forego some of these higher risk situations like going to bars, having crowded dinner parties. That may be one strategy for play dates that's much more realistic than trying to have a play date where you're keeping kids physically apart. The bubble or pod strategy does model really well because the models tend to assume a high percentage of compliance. Now, you can always tweak the models to reduce the compliance and then see what happens. But these models are very respond to the number that you put in because it is just a model for how much people are complying, and the moment just a few people aren't complying, it becomes harder to sustain this kind of idea. So I'm wondering what your instinct is about that. I mean, I know all the recommendations say, will find another family whose values match your family. I mean, the whole thing sounds sort of like you're trying to marry the other family, and within some realistic bounds, you could perhaps do that. But then you imagine your family has a bunch of kids, another family has a bunch of kids. People live in blended families today and complex families where children move from one house to another house. There are just so many different variables that, to my mind at least, make it a little harder to say with great confidence that we can be any perfectly locked in bubble or pod. If you're perfectly locked in the bubble or pod, then sure it doesn't it does not a problem at all. Yeah, I mean, it does depend on compliance. But I think the question is, what is the comparison group here? If we're making a decision about creating a pod with another household, what is the alt tternative approach that we're considering. Is it going back to business as usual and just saying I can't do this anymore. In that case, trying to create a pod will be a lower risk strategy. I think it's always important here to be thinking about what the counterfactual is, what is our alternative approach, and is this strategy potentially keeping us from something that would be much higher risk. The Netherlands, which has a history, at least a modern history of being realistic about sex and drugs, was recommending, actually pretty early in this process, that people should have what they called a sex buddy. Their words funny how people take English words and turn them into their own language, and that that should be people's solution for having a sexual life, not just a social life. More broadly, what's your reaction. I think it's a fantastic harm reduction approach that's really analogous to the social bubbles idea for households the pods. It's basically like a sex pod, where the overall framework is keep your contacts as minimal as possible. You want a few contacts as possibles, both socially and sexually, and the Netherlands had originally said don't have sex with anybody outside of your household, and single people revolted and said that's not fair. Sexual contact is a human need for many of us. So the Netherlands said, okay, here's the lowest risk way to have sexual contact, which is picking one person and sticking with them as long as possible and at least having just one partner at a time. And it's a perfect example of how to approach this with empathy and with the acceptance of the reality of human needs. And I think that's the kind of messaging that we need in the US. But I think the US will be slow to adopt for fear that by saying get a sex buddy, we are promoting risk taking that we want people to actually avoid. Epidemiologists like you wear two hats. One is a hat, which is a normative hat. You know, you tell us what to do to be safe doing that, and I'm grateful. The other is a predictive hat, where you're trying to figure out what the world is going to look like. So let me ask you to put on their predictive hat. I'm curious to know what you really in the real world. I think this is all going to look like at the end of the summer. That's a tough question. I get a bit depressed when I think about what things may look like. I feel like our government nationally has given up, not even that it necessarily was ever trying that hard to respond to this pandemic, but certainly is no longer trying at all. I think some states have also adopted that approach and have essentially given up, and we're now seeing the early results of that, with some very stark increases and cases and hospitalizations, and I think it's very hard to imagine going back to another lockdown in those areas. I think people will not accept it. Even if the state were to try to adopt it, I don't think people will accept it. And so I don't know how this is going to play out, but I think it's not going to be pretty, and it's I find it, actually, as a citizen, kind of heartbreaking. Just to follow the line of that scenario, Let's imagine that in a state like Arizona, the number of cases goes up, the state wants to respond by pushing for greater social distancing or even a lockdown, and the public just won't comply. We get a kind of spontaneous adoption by the public of the idea that we're going for her community. I mean, that is something where the government could in theory, really massively cracked down, But it's very unlikely that would happen given the structure of our democracy. If enough people don't want to comply, we probably won't get compliance. Then we'd have some places in the United States that we're actually adopting a everyone should get it strategy. Other places are very unlikely to go down that road. Does that seem inherently bad to you? You know, in constitutional law, which is what I do is my day job, we sometimes talk about the states as quote laboratories of democracy, which is meant as a metaphor. In this instance, it's not really even a metaphor. I mean, we're talking about the possibility that different states will actually genuinely try completely different things, and if there's a certain degree of isolation between them, maybe we'll just find out which one works better, works better for people's health, works better for the economy. Does that seem to you completely crazy? Well, the very states that are likely to go down the route you just described of refusing to comply with any future lockdown measures and just seeing what happens. Those are the states where we are likely to see the greatest inequities in how this pandemic plays out if we think about states in the South, in particular, where racial inequities and health, for example, are already stark, where the people who are most likely to still be working. I mean this true across the US. The people who are most likely to still be working and be exposed to the virus are people of color and people who are poor and need to be at work. So I would guess that the way that this natural experiment would play out would have some really unjust inequities in terms of who is impacted by the pandemic in ways that we've already seen, but I think will become exacerbated if we take a herd immunity approach. I mean, as you just as you said, we're already seeing that you're already three times more likely to die of COVID nineteen if you're African American. And indeed, I mean one of the things I was going to say about the spectrum of risk and the experiments with pods, all of it assumes a kind of model of what's the ideal thing. The ideal thing is the two parent family in its picket white fenced home, you know, maybe potting with another similar family, the idea being that everyone can afford not to be exposed for financial reasons. And then you know, if well, if she has somebody is single then and they're looking for some human or sexual contact, and you say, wow, monogamy at least would be the next best step. You know, the whole thing follows a kind of continuum towards the more more more normative picture of what we imagine upper middle class or middle class at least left to look like. So, I mean, what you're saying is true. I don't dispute it at all. But aren't don't we already see that those models are kind of dead ends. Yes, I think it's a great point that the assumption that somebody can comfortably pod with another family or have a sex buddy and make these calculated choices around risk, it's based in an assumption that somebody has some level of privilege to be able to do that. And it's abundantly clearer that in general, social distancing and calculated choices around risk are very much a privilege that are not afforded to people who have to return to work. Because the government has not supported them enough to allow them to stay home, and people who live in very crowded housing who can't necessarily distance and then make these controlled decisions around which families they are going to pod with. So I think it's a great point that needs to be acknowledged. I still think the public deserves some understanding of a spectrum of risk, and that everyone can benefit to some extent from learning more about their risk that goes beyond my risk is zero if I'm in my house, and my risk is one if I walk out my front door, which I think has led to a lot of confusion around where risk really lies and has prevented people from making the most informed decisions about their everyday lives and the choices that they've already been making for the last several months. Where can listeners see your infographic with a spectrum of risk? It is posted on Twitter and it has also been adapted by Vox. They put out a much more professional looking version, so I would encourage people to search for that. Julia, thank you so much for this analysis. It's really insightful, very powerful, and I think I and a lot of other people will think about it very very carefully in the weeks and months ahead. Thanks so much for having this is a great conversation. Listening to doctor Julia Marcus, I was deeply struck by a truth that seems to me pretty profound that she was getting at. Human beings have needs. Social life is indeed one of those fundamental human needs. To be social is part of what makes us human. And so says doctor Marcus, we need to have a life in the pandemic, and what we need to do then is to evaluate risk against the backdrop of the reality that we still have an imperative to have a life. Making that determination of how to have a life in the pandemic will be at the level of the individual and of the family. We need to keep in mind that it's a decision that will always be made against the backdrop of what privilege we may in fact have. No matter who you are, though, you still have to undergo some analysis of what the relative risks are that you can and are willing to take. And I, for one, believe we can do that better in the presence of knowledge and understanding than we could without it. Until the next time I speak to you, be careful, be safe, and be well. Deep background is brought to you by Pushkin Industries. Our producer is Lydia Jane Cott, with mastering by Jason Gambrell and Martin Gonzalez. Our showrunner is Sophia mckibbon. Our theme music is composed by Luis GERA special thanks to the Pushkin Brass, Malcolm Gladwell, Jake of Weisberg, and Mia Lobel. I'm Noah Feldman. I also write a regular column for Bloomberg Opinion, which you can find at bloomberg dot com slash Feldman. To discover Bloomberg's original slate of podcasts, go to Bloomberg dot com slash Podcasts. And one last thing. I just wrote a book called The Arab Winter Patrogedy. I would be delighted if you checked it out. If you liked what you heard today, please write a review or tell a friend. You can always let me know what you think on Twitter. My handle is Noah R. Feldman. This is deep background