Updated: Sep 30, 2020
It may come as a shock that an Infectious Disease physician would suggest something like this during a pandemic, so let’s get a couple of things straight. First off, I’m not a COVID denier. It’s very real and a significant threat to public health. I’ve had patients and even an extended family member die from it. Second, I take my duties as a physician very seriously. My goal is to help as many people as possible live longer and healthier lives through shared decision-making. The key here is remembering that every decision carries some measure of risk. Medical practice is never about eliminating risk and only sometimes about minimizing it. The real art of medicine is helping people make decisions consistent with their goals and desires while incurring an acceptable amount of risk.
Everyone’s tolerance for risk is different, so many will disagree with what I have to say here. If the thought of traveling right now terrifies you, it probably isn’t worth the worry and anxiety. Also, if you have a compromised immune system or serious health issues that put you at risk for worse outcomes with COVID-19, it may be too soon, and I would insist that you speak with your personal physicians before making any travel plans. I’m speaking largely to those healthy people on the fence, as well as those who would like to travel but feel that it’s off limits for the foreseeable future. After months of internal deliberations, I have arrived at the conclusion that we can, in fact, travel safely and responsibly even in the midst of this pandemic. Not only that, but I believe many of us will be better off for doing so.
Let’s start by addressing travel-specific risks. First, you need a way to get to your destination – most often in the US, that’s by private vehicle. In this situation, transmission risk is quite low because 1) you’ve probably already had close contact with anyone else in the car and 2) cars aren’t airtight, so there’s a constant supply of fresh air moving through. Unless you’re a rideshare driver or passenger, or perhaps you just decided to pick up a hitchhiker, you really don’t need to be masking in your own vehicle. Public transportation like buses and trains are a little different story – certainly riskier than taking your personal vehicle, but not inordinately so if riders are masking and attempting to maintain distance. In many places, public transit now operates at reduced capacity to promote social distancing, and many local governments have mask ordinances. While a private vehicle is preferable, I believe that public transportation can be utilized responsibly if proper precautions are taken.
Travel by sea, on the other hand, is probably not a good idea during the pandemic – at least in the way we usually approach it in the US. Cruise ships were known for being conducive to disease outbreaks even before the pandemic, and some of the earliest large clusters of COVID-19 were recorded on these floating cities. Outside of your personal cabin, which is generally a bit too small by design, the ship is one big shared space with few options for escaping the crowd. Ferries are a better bet with their open spaces and lower total capacity, as well as their significantly shorter duration of travel. Small, private vessels are best for the same reason that private automobiles are best among land transportation, although this mode of transportation is unlikely to be available to the population at large.
But what if you’re traveling by air? Being sealed in an airplane compartment with dozens, if not hundreds of other people may seem like a bad idea, but flying is safer than you might think when it comes to disease transmission. On March 9, in the days before airlines widely implemented additional hygiene protocols, a flight departed Tel Aviv, Israel and flew for 4 hours and 40 minutes to Frankfurt, Germany. Testing upon arrival in Frankfurt revealed that 7 out of 24 members of a German tour group had acquired COVID-19 while traveling. A research group then followed 71 of the remaining 78 passengers on the flight and determined that there were only two probable transmission events on the flight. Think about that for a moment – out of 71 people in a small, enclosed space with 7 known COVID-19 cases for almost 5 hours, only 2 additional people were infected. Maybe. Even in those cases, follow up testing was delayed by weeks, so the newly-infected passengers could have acquired COVID-19 after the flight.
These observations do not suggest that COVID isn’t as infectious as we thought. Rather, it’s a testament to the effectiveness of air handling systems on commercial airliners. Modern passenger jets continuously cycle air through the cabin from ceiling to floor in an effort to sweep any pathogens in the air down and away from passengers. They also move cabin air through HEPA filters capable of trapping particles as small as a virus. Furthermore, they only recycle about 25% of cabin air with each pass, venting the other 75% overboard and pulling in fresh atmospheric air to be pressurized and filtered. With these measures, a typical single-aisle jet like a Boeing 737 completely turns over the cabin air content every 3 minutes. If these measures could minimize COVID transmission in the absence of masking and reduced capacity, then current airline travel should be quite safe with the additional precautions.
Selecting an itinerary
As for destination and activity selection, it’s really a matter of applying transmission principles. Now is not a good time, for example, to join a large tour group of strangers from all over the world and visit a crowded museum. Camping with your family would be closer to ideal, but even a beach vacation is fine as long as beachgoers aren’t all packed into a small area. Hostels are probably not the way to go when it comes to lodging, but hotels can be a safe option with masking and social distancing in common areas. Private rentals are even better. I see a lot of places touting their thorough new cleaning processes, which is a nice gesture but probably adds very little in terms of transmission protection. As I’ve discussed before, it’s highly unlikely that you’ll acquire COVID-19 from a contaminated surface – especially if the infected person vacated the space hours before your arrival. Just keep up the regular hand hygiene and it won’t matter what you touch in the environment.
Is it worth the risk?
So, travel can be pursued with little risk for COVID transmission. But why take even that small risk when you could be safely cut off from the world at home? Well, as I said earlier, every decision carries some degree of risk, and that includes home quarantine. In the months following widespread lockdown measures in the US, we’ve seen rates of depression and alcohol abuse increase. I’m quite sure that many of us also gained weight and lost some of our physical conditioning during this time. At least, I did, and I’m still working to undo the damage. Under pre-pandemic circumstances, we had data to show that vacations benefitted individual health, mood, job performance and even long-term mortality. Not staycations – real vacations that remove you from the environment you associate with stress and dissatisfaction. How much more might some additional time out of the house benefit us now? Americans already get significantly less time off from work than other industrialized countries, and we weren’t even using all of that time before COVID hit – in 2018, we collectively forfeited at least 236 million vacation days. Under “normal” circumstances, 75% of American workers don’t take all of their vacation days, and 42% don’t take any vacation days. It was bad before, and becoming a nation of shut-ins has only worsened our collective physical and mental health.
That’s not to say that quarantine measures weren’t necessary as the pandemic took off. I was definitely on the side of more conservative measures until we had a better understanding of what we were dealing with when it came to COVID-19. Lockdowns probably saved hundreds of thousands of lives in the US by allowing our healthcare infrastructure to keep up with demand in most places. Now that we know much more about disease transmission and have real life experience to show which interventions work to slow the spread of COVID-19, I think it’s time to venture outside the plastic bubble again. Several COVID vaccines are looking promising, but it will be months before we can administer them to the population at large (personally, I’m guessing first quarter of 2021). In the meantime, I believe we have reached a point where, as long as travelers are healthy and take reasonable precautions, the health benefits of leisure time outside the home outweigh the potential for COVID transmission.
Lest you think I don’t practice what I preach, I’m writing this article on a trip to Antigua. On the way here, flight capacity was limited, and everyone was required to wear a mask at all times unless eating or drinking. In lieu of traditional beverage service, packaged snacks and bottled water were doled out in plastic bags as passengers boarded the plane. Antigua, like many places outside the US, currently requires a negative COVID test for entry, so I got my nasopharyngeal swab 5 days prior in Denver and brought along the test result. My wife and I rented a car on arrival, and we’re staying in a private hotel room where staff and patrons are pretty consistent about wearing masks in common areas. We remove our masks when we’re safely spaced out on the beach, swimming, riding in the car, dining or spending time in our room. It’s an adjustment, but I believe this sort of arrangement is what constitutes responsible travel for the time being.
COVID is already out of containment
In case you’re worried about being some country’s patient zero (i.e. the hapless first person to bring the disease in), there really aren’t many places left in the world reporting zero COVID-19 cases. Most of them are isolated islands in the Pacific, and several of those aren’t allowing tourists in for now, so it’s kind of a moot point. If you’re traveling from the US, many popular tourist destinations in Europe are still closed to visitors due to the significantly higher rates of COVID-19 in the US, so your list of travel options will be limited from the outset. For the remainder of countries allowing American tourists, many have testing and/or quarantine requirements to enter, so there’s not a lot of room for travelers to be irresponsible – if you want in the country, you have to play by their rules. It’s not what we’re accustomed to, but it does make it much harder for an individual traveler to play fast and loose with other people’s risk for COVID.
The new face of travel
So, travel looks quite a bit different now. Most airports have masking requirements. Nearly every queue has markers on the floor to keep people 6 feet apart. Airport restaurants have either spaced out their dining tables or done away with them altogether, requiring people to carry out instead. Some businesses require temperature screens before customers can enter. Building occupancy may be limited. Inconvenient? Yes. For me, it’s absolutely worth the minor sacrifices to get away from the daily grind for a while, and I suspect that understanding the balance of risks will influence others to feel the same. Life in general will be different until we can get a majority of people vaccinated against COVID-19, and even then, a lot of things won’t return to their pre-pandemic state. It doesn’t mean, however, that we can’t take measured steps toward normalcy.
I suspect my suggestions here will be somewhat controversial. I recognize that they do not represent the “ideal” course for containing a pandemic virus, but I’ve always preferred a pragmatic approach when it comes to improving personal health. The unfortunate reality is that we will never convince enough people in the US to adhere strictly to transmission precautions – that much has become clear after months of public education campaigns and policy changes at various levels of government. If we had hope of arresting the spread of COVID-19 in the immediate future, my message to the US populace would be very different, but I’m dealing with the reality of our present situation. A widespread vaccine is still, optimistically, 6 months away. The majority of Americans who have agreed to observe proper precautions have now been stuck at home for the better part of 6 months with their physical and mental health declining. We must consider the balance of health impacts here – COVID transmission is unlikely with common-sense precautions, while languishing in home quarantine is nearly inevitable. Even if you keep up your exercise routine inside the house, we have ample data to show that people fare better in terms of health and productivity with periodic breaks from their conventional existence.
This is uncharted territory for all of us. The last time the world faced anything like COVID-19 was during the 1918 influenza pandemic, and even that’s not a fair comparison, considering the sweeping changes in personal mobility and communication over the last century. Experts do the best they can with the information available to them, and with novel diseases, this will always involve some trial and error. From my perspective, however, the dynamics of COVID-19 are coming into focus, and I believe we have reached a point – at least in the US – where the detrimental health effects of quarantine have surpassed the risks of venturing outside our respective home areas. We will be riding this pandemic out for months to come, but it doesn’t mean that we should be sacrificing other facets of our health in the meantime.
Don’t misunderstand me – this is not a call to return to the pre-pandemic status quo. You should wear a mask around others outside your household, particularly in indoor settings. Keep your distance. Wash your hands. Investigate COVID rates and policies at your destination. Get some form of COVID screening before you travel, and don’t travel if you feel ill. Just know that, for healthy people going stir-crazy at home right now, you don’t necessarily have to wait for the COVID vaccine to leave the house again. My goal here is to outline the risks and benefits of travel during this time and allow people to make informed decisions. Is it time to re-evaluate your travel plans?