In order to protect ourselves from coronaviruses, pandemic influenza, and other contagious outbreaks, we need to understand bubbles.
Like ‘circuit-breaker’, ‘cocooning’ and ‘social distancing’, the word ‘bubble’ has become a part of the world’s post-pandemic lexicon. We talked about ‘travel bubbles’ in May as European lockdowns were coming to an end. Siouxse Wiles and Toby Morris won international acclaim for their use of bubbles in their COVID education series 'Flatten the Curve' (and you can see a sample fo their work in the post image). Fianna Fáil introduced ‘support bubbles’ to mitigate the social isolation experienced by many during Ireland's repeated lockdowns.
More recently, the Flaming Lips (who else?) preformed in the world’s first space bubble concert.
In this piece, I would like to present a broader definition of the concept of a bubble, because these assorted policies all share a characteristic structure and purpose that makes them particularly useful in a pandemic. Bubbles can provide robust protection against contagious viruses, while also maintaining the flexibility to allow them to be used in almost any environment. This combination of resilience and adaptability makes them effective at constraining the transmission of the virus. Moreover, if we coordinate their implementation across the nation, bubbles can form the building blocks of a SARS-COV-2 elimination strategy.
But first, what is a bubble?
Clearly, this is a figurative concept; actual, physical bubbles are neither robust nor flexible. In the context of a contagious outbreak however, a bubble is an area that has been isolated and sealed off from everything around it. Life continues inside the bubble just as it does on the outside, but the two populations are kept apart so that the susceptible and the infected never meet.
The seal around the bubble is ‘airtight’, and it is this structural impermeability that makes the bubble an essential risk management tool in a contagion. A harsh national lockdown can reduce the number of infections by suspending most human interaction (a high price to pay), but only a bubble can cut the lines of transmission between populations.
The bubble is the true circuit-breaker
For those inside the bubble, the external threat has been eliminated so they have one less risk to worry about. Of equal importance, the bubble creates a boundary around the virus, making the outbreak finite and the problem solvable. In much the same way that plugging the hole in your boat allows you to bail the water out, creating a bubble lays the foundation for a COVID elimination strategy.
I described bubbles before as being applied to an ‘area’. I deliberately chose a general purpose word because a bubble is a general purpose tool. It’s flexible, it scales, and it can be adapted to any situation - an 'area' could be anything.
When we self-isolate, we cut ourselves off from the rest of the population because we don’t want to risk spreading the virus. In doing so, we create a personal bubble around ourselves. When a nation closes its borders, it puts the entire population into an international travel bubble – a protective measure that is especially effective at the early stages of an outbreak. A quarantine facility is a bubble of bubbles: there is a bubble around the whole building, with smaller bubbles around each of its rooms to ensure that the virus cannot transmit in any direction.
We can see bubbles everywhere in our COVID-19 defences, and it’s no surprise; they have been tried and tested over centuries and they continue to prove their worth. By this stage we’ve all heard about the origin of quarantines in Venice and Dubrovnik during the Middle Ages. The islands on which arrivals were stationed were bubbles. The term 'cordon sanitaire' dates back to the 1800s, but it's the same idea: it's a bubble that keeps the susceptible and the infected apart.
Regardless of the level of technological sophistication of our societies, bubbles will continue to be an indispensable component of our outbreak response plans. The challenge for Ireland is to find a way to coordinate our bubbles with our other public health measures, so that we can achieve our ultimate goal of eliminating the virus.
How to eliminate the virus with bubbles (and rapid tests)
We could put a county into a bubble. We could seal it off from the counties around it, implement temporary restrictions on internal movement, flood it with tests and other medical resources, and steadily suppress the virus until it was eliminated. That is a possibility – and I don’t mean a theoretical possibility – I mean, it is an option that is available to us right now. If we chose to take this approach in counties with historically low incidences of the virus, like Kerry, Waterford, Sligo, Leitrim, or Carlow, they would all be recording zero case days within a few weeks.
That is not to say their problems would be solved in a few weeks. With elimination as the goal, they would need to go another couple of weeks without recording any new cases in order to be confident that community transmission had truly ended. Once they reached that point, they could start lifting all internal restrictions – permanently. The county would still be in its bubble, but the fear and uncertainty would be gone, and life would feel like it was finally getting back to normal.
While a local bubble might offer some novelty in the short-term, there would eventually be a desire to reconnect with the rest of the country. Even those with the strongest sense of county pride would recognise that life could only return to normal once the virus had eliminated from every county.
How to speed the process of elimination
So, instead of putting counties into bubbles one by one – a painfully slow process – could we put a group of counties into bubbles at the same time?
Consider Connaught; it has five, sparsely populated counties, and each one of them has achieved multiple days in a row without recording a case. Even allowing for poor testing in the first half of the year, there is little to suggest an underlying complexity that couldn’t be overcome with a sensible plan and adequate medical resources, particularly rapid testing capacity (you can read more on rapid testing here).
In that scenario, all of these counties could be recording zero case days within a few weeks. From there, the individual counties would proceed as before: establish two weeks without community transmission before removing their internal restrictions, and then combining their county bubbles into a larger provincial bubble.
Could we clear all of Connaught in 6 weeks? With a stockpile of rapid tests – yes, and easily so!
Could we repeat this process for each province, growing the protective bubble until it covered the whole country? How long would that take? Or should we skip the provinces, and just put every county into a bubble from the start? Which approach would be quicker? Which would place less of a burden on the people?
More importantly though, why haven’t these questions been asked already? This is a conversation we could have had months ago. There is nothing in this framework that hasn’t been done already, either in Ireland or in any of the more competent nations, so why have we made no progress with our policies since March?
Where does that leave us?
The point is not to advocate for one strategy or one particular policy. In the first place, it is to explain the concept of a bubble and to encourage the reader to look for them in our policies: are we creating bubbles? Are they working? If not, why not?
Secondly, it is to argue that yes, elimination is possible, and to support that position by presenting a framework through which elimination could be achieved. Granted, this framework only describes one layer of the solution, and it raises many questions of its own, but wouldn’t this discussion be a better use of our time? Wouldn’t you rather debate solutions, instead of pointing fingers at each other, arguing over €9 meals, Gardaí in the underwear aisles, golfgate, dentist appointments in Tenerife, and sitting around getting angry and depressed as our lives are wasted away.
Whatever path we take, tests will be run, money will be spent, debt will be accrued, excuses will be made, teeth will be gnashed, and there will definitely be more lockdowns. The question is whether our time and efforts are put into a strategy that finally solves our problems, or whether we continue to squander our resources and our lives on a plan without a goal.