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COVID-19: There’s No Space at Home for the Holidays?

Back of heads of older couple looking at laptop with images of family waving back at themAs a public health–oriented academic physician, I have found myself queried by friends and family more than usual during the eight months in which COVID-19 has upended our lives. It makes sense that they might expect me to be better positioned to know what’s true and what’s not, as we’ve all slogged through daily information dumps that are some combination of confusing, contradictory, and inconclusive.

These questions have often made me uncomfortable, as I had neither “inside information” nor a direct line to “the truth.” But I’ve come to realize that where I can try to be helpful is around the understandable but irrational and unachievable desire for certitude. After all, understanding uncertainty, accepting it, and making reasonable inferences and decisions despite it have pretty much been the core of my professional life.

So to answer the current urgent question “How do we handle Thanksgiving―and the rest of this holiday season?” (replacing last month’s urgent question “How do we handle voting?” and the prior month’s “How do we handle schooling our kids?”) I can offer only this: I’m struggling with my own plans in the context of the current whirl of information, particularly the CDC’s latest published COVID-19 guidance.

Remember, basic decision-making principles apply: you use the best available data and your own priorities and preferences to select an approach that yields the lowest risk-benefit ratio.

The CDC’s recommendations are clear, concise, evidence-based, and reasonable—but translating them (most of which we all already know: masks, distancing, handwashing, staying outdoors) into individual decision-making isn’t a trivial matter. Because of the pandemic, the stakes are especially high in this situation: life or death. And while this is always a challenging and highly personal process, every choice you make directly affects others in a different way than most medical decisions do.

 The Safest Celebration

First, the CDC says “The safest way to celebrate Thanksgiving this year is to celebrate with people in your household.” This is clear, and 99% true. It’s worth noting that the truly safest way is to celebrate it alone, as there is always a non-zero risk that someone in your “household” may have been exposed and may be an asymptomatic carrier. Not to be a Debbie Downer, but this is a framework we all must accept: that any choice other than strict isolation from everyone and everything confers an unknown, non-zero risk. It is likely to be quite small, but rises as local infection/positivity rates increase (as is currently happening almost everywhere in the United States, exactly as predicted by the experts).

For those whose households include everyone you’d usually spend Thanksgiving with, this pretty much solves your dilemma. My household comprises my wife and me, so I’m not quite there. Don’t get me wrong: I love my wife, and I am deeply thankful to have her in my life―but after sharing hundreds of meals with her, and no one else, over the past eight months, having yet another dinner alone together isn’t going to be exactly festive or celebratory for either of us.

This leads me to the next sentence in the CDC guidance, which states, “If you do plan to spend Thanksgiving with people outside your household, take steps to make your celebration safer.” We should all already know this drill: face coverings, distancing, handwashing, staying outdoors, and not touching each other or sharing dishes, utensils, and the like. The guidelines go on to provide some specific ideas, but the big picture is what counts, and anyone who doesn’t know and practice all of this already is either stupid, irresponsible, or both.

 Risks and Benefits

The guidance is smart about risk and risk mitigation, but silent on benefit―and no one can calculate a risk/benefit ratio without the denominator! This silence may be predicated on the simplistic assumption that as Americans, we are all (equally) desirous of celebrating Thanksgiving with friends and family. But I think that’s a cop-out, and each individual has different preferences and priorities. For some, the driver might be your sister’s special stuffing or cranberry bread. Want to reduce your risk in this case? Have your sister mail her dishes in advance, and share them during a Zoom gathering.

For me, it does have to do with my sister, who has lovingly hosted our annual family Thanksgiving for many years. Indeed, as a brilliant science and health writer, she has even written about the psychological and health benefits of spending this time with one’s siblings. But that was written during the Before COVID-19 Time, when none of us could even imagine being where we are this year. I confess, however, that just as with my personal household, as much as I love seeing my sister and brother-in-law and their kids and my kids and everyone’s S.O.s, the incremental benefit I see from sharing this meal with them physically isn’t large enough to justify possibly getting sick, even dying.

But I’m not done yet, as a key variable is missing from this equation: seeing my two grandsons and my two grandnieces. These are benefits that are both incremental and profound because, as most grandparents know (and endlessly assert to those around them), there is nothing in this world that provokes a greater and purer sense of joy than being with one’s grandchildren. So I’ll need to factor that in—along with considerations of my likelihood of carrying the infection to others, and how it would affect those nearest and dearest to me in the world if any of us were to contract COVID-19 sometime after Thanksgiving. While we wouldn’t know with certainty whether the cases were contracted at the gathering or elsewhere, that wouldn’t stop anyone’s feelings of guilt—and I wouldn’t want that.

 Finding Certainty in Uncertainty

All this leads me back to uncertainty. I accept its inevitability and have learned to make many clinical and population-health decisions in spite of it. When it comes to Thanksgiving, I haven’t formed a conclusion yet; what I’m sharing here is pretty much as far as I’ve gotten in the process. Perhaps new data will make my decision easier: for instance, if the positivity rates in New York continue to increase, my decision may become reasonably clear (“too much risk to justify the benefit”).  Of course, rates could reverse course and decrease between now and then, but I think we’ve all seen the fruits of such magical thinking.

Of this I am certain: this holiday season will not be normal and for most of us will fall far short of what we’d want it to be. And as much as we are all sick and tired and demoralized by the dramatic and seemingly endless adjustments we’ve all had to make―and will continue to make―we will ultimately decide what’s best for our families, our communities, and ourselves.

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