What We Can Learn From the Most Successful Covid-19 Bubbles
By: Erik Ofgang
Tags: Health, Covid 19, Pandemic, Coronavirus, Public Health

The staff at the Berkshire Theatre Group desperately wanted the show to go on.

In March, theaters across the globe began canceling their productions, but Alex James, the company manager of the rural Massachusetts theater group, says she and her co-workers were determined to find a safe way to stage a show in the summer.

One of her colleagues came across a story about how Tyler Perry Studios planned on shooting four of its shows by creating a “Covid bubble.” During production, each show’s cast and crew would quarantine at the company’s Atlanta studio complex, creating a protective pod that would hopefully ensure people wouldn’t catch Covid-19 and spread it.

This bubble idea appealed to the Berkshire Theatre team.

“We thought that for a cast of a show that would be our best bet,” James says.

Since March, various types of Covid bubbles have popped up across the globe. They have ranged from large — enclosing vast sections of countries — to small, two or three families teaming up and assuming each others’ risk. In Connecticut, an assisted living facility owner paid his staff to live at the facility from late March until the end of May in order to protect his older residents. The NHL and NBA both resumed their seasons late in the summer by having players enter bubbles. The latter two bubbles have received significant praise for their apparent success. NHL players and staff isolated within bubbles in Edmonton and Toronto, Canada, where cases of the virus are relatively low, while the NBA’s bubble was established at Disney in Orlando, Florida — a state where the spread of the virus was rampant and thousands of people were being infected each day of the summer. Even so, both sports bubbles have succeeded and the hockey and basketball leagues have avoided the positive coronavirus cases that have hampered athletes in the MLB and the NFL.

Many public health experts applaud bubbles as a way to resume some aspects of society even as cases surge.

“For community institutions, there’s a responsibility to strive for that bubble ideal as much as possible,” says Stephen Kissler, a research fellow in the department of immunology and infectious diseases at Harvard’s T.H. Chan School of Public Health. He says that when done right a bubble can be a boon socially. “We are still able to play sports, and we are still able to have plays and art.”

The Berkshire Theatre Group designed its bubble strategy in conjunction with medical experts at Berkshire Health Systems, a nearby hospital and health care group, and the Actors’ Equity Association, a union representing more than 51,000 actors and stage managers. Because of these efforts, the group’s production of Godspell was the first musical in the U.S. since Covid-19 entered the country to be approved by the Actors’ Equity Association. The production ran from August 7 to September 20 at the Colonial Theatre in Pittsfield, Massachusetts. Throughout rehearsals and the show’s run, cast members lived together in a former bed and breakfast owned by the theater company. They remained mostly sequestered from the world, only interacting with each other and select theater staff members who were also quarantining. During shows, audience members had to wear masks and sat more than 25 feet away (because the performers were singing, Equity officials and Massachusetts health officials wanted extra distance).

Performers were allowed to get takeout and make essential trips to places such as the grocery store or pharmacy while masked, but they were not permitted to dine out or visit family and friends without socially distancing.

These precautions and those employed within other bubbles limit but do not eliminate risk, experts say.

“There’s no bubble that’s perfectly contained. There’s always going to be some leak somewhere,” Kissler says. “People need to be fed. And so you need to have people who are bringing in food. There are always opportunities for transmission there. Making sure that those opportunities are as minimal as possible is really important.”

To help address this, the NHL had categories for different people who entered the bubble. Players and team and league staff were labeled category one and two and lived within a fenced-off secure zone. Others labeled category three and four lived off-site and entered the secure area but had minimum interaction with players. These included hotel security, housekeeping staff, and others.

Melissa Hawkins, an epidemiologist and director of the public health scholars program at American University, says bubbles are a good risk reduction strategy that she likens to safe sex education versus abstinence education.

“The only way to prevent pregnancy or sexually transmitted diseases or infections is to not have sex, we agree on that,” she says. “But abstinence-only approaches don’t work.”

The risk involved in bubbles is why frequent testing is a vital part of an effective bubble strategy. Those in the bubble at the Berkshire Theatre were tested three times a week.

“We really got to know the people who did the test,” James says.

Many public health experts applaud bubbles as a way to resume some aspects of society even as cases surge.

Geographic bubbles

Canada’s “Atlantic bubble” encapsulates four provinces: New Brunswick, Nova Scotia, Prince Edward Island, and Newfoundland and Labrador. Though essential workers can cross into and out of the region, and people moving there can enter after appropriate quarantine, it is mostly closed to the outside world.

Though restrictive, the bubble was designed to enhance freedom within its boundaries, says Susan Kirkland, the head of public health and epidemiology at Dalhousie University in Halifax, who has lived within the bubble since it went into effect in July.

“The intent was that there could be movement and flow across all four provinces, and perhaps it would revive some of the economic activity because a large economic driver in the Atlantic region is tourism,” Kirkland says. “For the Atlantic residents, there are still some requirements. You might have to stop at borders and go through forms and checklists and things like that, but there’s no requirement to quarantine.”

So far the strategy has been a tremendous success. Last week there were only six confirmed cases of the virus in the four provinces, less than one case per 100,000 people.

People continue to wear masks and be cautious, and life is far from normal within the bubble, but those who do venture into the world can do it with confidence that their chances of infection are low.

New Zealand is another large area with notable success establishing a protective bubble from the virus, and as with that island country, Kirkland says geography has certainly played a role in the Atlantic bubble’s feasibility. There are limited roads into the region, so setting up checkpoints is feasible. “It’s not like the border between Canada and the U.S. where there are hundreds and hundreds of entry points,” Kirkland says.

Luck and low-density population also helped.

“We had the advantage of low infection to begin with,” Kirkland says. “We have a lot of rural communities. Our cities are large but not that large.”

In the U.S. more than 20 U.S. states have enacted interstate travel restrictions, but there are no checkpoints or roadblocks and little evidence of widespread enforcement of quarantine requirements, says David M. Studdert, a professor at the Stanford University schools of law and medicine. Even with limited enforcement, these rules have encountered opposition. Kentucky’s orders that everyone entering the state self-quarantine for 14 days was suspended by one court, while in Maine an alliance of campground and restaurant owners have challenged the state’s self-quarantine mandate for visitors.

“There is a constitutional right to travel interstate in the U.S. That’s a pretty well-established freedom,” says Studdert who was the lead author of a recent New England Journal of Medicine perspective that examined how courts will handle challenges to state travel restrictions. “In constitutional law, there’s different levels of scrutiny that a court can apply. If they apply the most stringent level of scrutiny, what’s often referred to as strict scrutiny, it’s extremely hard for the government to win in that situation.”

He adds, in this instance courts would normally, “apply strict scrutiny, because it’s a constitutional protection. But there’s another body of law that says in public health crises governments, essentially, get a fairly free hand and you shouldn’t apply that strict level of scrutiny.”

Beyond the law, for society it’s “a social value question really, would you prefer to have your travel restricted, and then have more freedoms in other daily activities?” Studdert says. “Or would you prefer to have open borders, but yet need to really clamp down all across the country or a state or region?”

Though Studdert thinks bubbles can be a valuable strategy in these times, he says, it’s not a bad thing that the U.S.courts are scrutinizing these rulings. “It is one of those tools like so many tools of public health that if you wanted to use it as a pretext for something else, like keeping poor people out of your state, or restricting benefits, that would be easy to do.”

As with so much about Covid-19, even effective geographical bubbles have their potential downsides. Kirkland notes that the low spread of Covid-19 within the Atlantic Bubble may be “a bit of a blessing and a curse. Because although we’ve prevented Covid it also means that virtually all of the population is at risk of getting Covid because they have not developed any immunity.”

Kissler, from Harvard’s T.H. Chan School of Public Health, says a consensus has emerged among experts from history and models that for pandemic-causing respiratory illnesses, large-scale bubbles delay but do not prevent the virus from spreading. “It just sort of pushes the epidemic down the road a little ways,” he says. “And that’s because it’s so difficult to maintain those boundaries on that sort of scale.”

He adds that New Zealand has defied this history so far, and delaying the viruses spread is not without benefit. “By delaying an epidemic, you have more opportunities to develop treatments and to institute other public health measures.”

The smallest bubbles

On the opposite end of the bubble spectrum are the bubbles two or more households form. These have also been dubbed quaranteams or pods. Whatever you call them, Hawkins, from the American University, is a proponent. A mother of four, she says her family joined a pod with another family because of their mutual child care needs and also so that kids in both families can socialize. During the summer, the kids spent most of their time outdoors but now the families alternate which house is hosting remote school days.

Some families have created bubbles with several different households, but if too many people join the pod, Hawkins says you get a “leaky bubble.”

Regardless of their size, bubbles are often only as strong as their weakest member, which is why everyone in them has to be on the same page, and trust and mutual accountability is vital.

“We are in constant communication,” Hawkins says. She adds those who enter a bubble together need to be willing “to have difficult and challenging conversations.”

Hawkins’ family and her friend’s family started their bubble in May and will continue it through the winter. “I think it’s important to double down on our quaranteam given there are going to be less opportunities to be outside because of the cold weather,” Hawkins says. “It’s also a good time to reevaluate and reassess the guidelines; the bubble was starting to get leaky this summer. Since there will be flu and other respiratory infections circulating this winter, along with the coronavirus, we will be relying on the shared guidelines of our quaranteam.”

Trust is also what made the bubble for Berkshire Theatre Group’s production of Godspell work.

Isabel Jordan, a 21-year-old performer studying theater at New York University’s Tisch School of the Arts, was cast in the show after auditioning via Zoom. She says everyone involved was mindful that what they did could serve as a model for other theaters to return to the stage, and they took care to be safe for each other and for the theater world in general.

“There wasn’t any moment during this process that I thought someone was going to break the bubble,” she says. “I think artists have a deep care for one another and truly, truly want to look out for each other. I felt safe the whole time.”