COMMENTARY

COVID Thanksgiving Analogies: Drunk Driving or Safe Sex?

F. Perry Wilson, MD, MSCE

Disclosures

November 24, 2020

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This transcript has been edited for clarity.

Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I'm Dr F. Perry Wilson from the Yale School of Medicine.

If you got called by a friend or family member for advice about how to stay safe while driving drunk, what would you say to them? Would you talk about wearing a seatbelt? Or might you tell them to throw their keys in the nearest river?

As the holidays loom and the coronavirus pandemic surges, more and more health professionals are being asked a version of this question: How can I stay safe while still celebrating a large family Thanksgiving?

How should we respond to that? There's a good argument, as pointed out by Vinay Prasad, that demanding abstinence hasn't worked for other health conditions, so why should we expect it to work now?

No one has ever really asked me for tips about driving drunk, but let's run with the analogy for a bit.

People do drive drunk. People will drive drunk. Should we be giving advice on how to do it safely? You know: "Hey don't do it; but if you do, be careful."

I picked this example because we are in a tricky situation when it comes to public health messaging about COVID and Thanksgiving and the other impending holidays. The data are pretty clear. We have case rates spiking all over the country, record hospitalizations, and a daily death toll that is already above the second wave in the summer and does not seem to be abating.

Source: The COVID Tracking Project

We know that indoor gatherings are a major transmission risk and that houses are often quite poorly ventilated — deliberately, in fact, to preserve energy costs. Modeling studies suggest that in much of the country, if 10 people were to gather together, the risk that at least one of them will have COVID-19 is above 20%.

Chande AT, et al. Interactive COVID-19 Event Risk Assessment Planning Tool.

That's crazy. The vast majority of public health experts — and most recently the CDC — have made clear recommendations: Do not travel for Thanksgiving this year.

Clearly, the safest choice is to simply celebrate with your immediate household.

But we know that's not what everyone is going to do. Airports are filling up with travelers. Prominent journalists have fretted but ultimately decided that the benefit of seeing families is worth the risk.

And we all know the advice that we could give here. The CDC even provides it, shrugging their shoulders at their own stay-home recommendation: Wear masks, stay outside if possible, wash your hands.

This has led to a bit of a crisis of analogies when it comes to public health messaging. Should we be treating a big Thanksgiving like drunk driving (ie, don't do it no matter what)? Or like how we treat safe sex (ie, we know you're going to do it, so please be safe)?

I actually posed that question to the medTwitter community.

https://twitter.com/fperrywilson/status/1329167636857380864

In this completely nonscientific poll, you can see that the majority are in favor of the drunk driving side of things, but plenty of folks think it's our role to ensure that if people are assuming some risk, we should help them minimize it as much as possible.

We need to come together on this messaging, because mixed messaging may be more damaging than no messaging at all.

What's the risk of a "don't do it" approach? Well, if we extrapolate from the abstinence-only literature, we might expect this line of messaging to make things worse — to increase risky behaviors, like sharing utensils — at holiday time.

Stanger-Hall and Hall. PLoS One. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0024658

On the other hand, the data to support safe sex practices are way more solid than those to promote safe Thanksgiving practices. Like, do I have hard data to suggest that leaving windows open reduces the risk for transmission of COVID? Not really. I mean, not of the quality that leads us to normally make recommendations.

In the end, our advice to stay safe during Thanksgiving is based on some biological plausibility and a healthy amount of common sense. But if push comes to shove, I'm not sure how safe those tips and tricks will make us. This lands me on the drunk driving side of the issue; I'm just not sure that the tips I could give are really that effective, and a false sense of security may be the worst side dish of all.

I live in Connecticut, within 20 minutes of my three sisters, their families, and our parents. They're taking my advice; we're all just saying no. It's a Zoom Thanksgiving this year — but hopefully only this year.

F. Perry Wilson, MD, MSCE, is an associate professor of medicine and director of Yale's Clinical and Translational Research Accelerator. His science communication work can be found in the Huffington Post, on NPR, and here on Medscape. He tweets @fperrywilson and hosts a repository of his communication work at www.methodsman.com.

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