Because of COVID-19 we agreed that we should no longer shake hands. However should we be “shaking” or “bumping” elbows?

With more than 23 millions of individuals infected with the severe acute respiratory syndrome coronavirus 2 (SARS-Cov2) and more than 800 thousands deaths across the world as of August 24th 2020 [1], the coronavirus disease 2019 (COVID-19) has established itself as the most frightening public health threats in over a century. It has been and remains a major issue for human kind. COVID-19 was first reported in Wuhan, China, in December 2019 [2]. The disease is transmitted from human to human by multiple means, namely, by droplets, aerosols and fomites [3]

At the beginning of the pandemic, many people were comparing it with the flu and were not taking it seriously. It is obvious now that this is completely different from the flu. There is no possible comparison in regards to the effect of the virus, its virulence, its mortality rate and its ability to make members of several communities mourn their loved ones.

A lot of emphasis have been rightly put on prevention, encouraging community members to always wash their hands, avoid touching their faces, avoid shaking hands, cover their coughs with the inside part of their elbows, practice social distancing and to always wear a face mask particularly when social distancing is difficult to do or is compromised.

Since people are encouraged not to shake hands, we have observed many individuals “shaking elbows” as a way to interact with and greet other people. People are keen to continue showing courtesy and fairness to others despite the fact that the coronavirus pandemic has been ravaging communities everywhere in the world.

Looking at people touching or bumping their elbows or “shaking elbows” as a way to greet others makes us think of infection prevention, and disease control. Health experts and epidemiologists have been encouraging people to cough or sneeze in their elbows. Since March 2020 I have seen an increasing number of individuals greeting others by “shaking their elbows” whereas their elbows are where they cough and sneeze. I am quite interested in finding out what is the risk of transmission via “elbow shaking” overall. I suspect that it might be a minimal risk but I believe this is an aspect of the pandemic that is worth exploring and investigating.  I believe that the risk would depend on whether the elbow is exposed or covered with clothes. People cough or sneeze in the internal part of their elbows and bump or “shake” the external part of the elbows. Nevertheless, there might be some level of risks in bumping or shaking elbows. Since many people are coughing and sneezing into their elbows and they usually use their elbows to greet others, I would not be surprised to see that there is some transmission of infection via the elbows.

In general, infected people spread viral particles whenever they talk, breathe, cough or sneeze [4]. Such viral particles are known to be encapsulated in globs of mucus, saliva, and water, and the fate or behavior of globs in the environment depends on the size of the globs. Bigger globs fall faster than they evaporate so that they splash down nearby in the form of droplets. Smaller globs evaporate faster in the form of aerosols, and linger in the air and drift farther away than the droplets do [5 – 6].

There has been no discernible evidence on the minimum infectious viral load for COVID_19 pandemic but many researchers speculate that a few hundred or one thousand of SARS-CoV2 would be enough to cause infection and then disease among susceptible hosts. A single cough releases about 3,000 droplets and droplets travel at approximately 50 miles per hour. A sneeze releases about 30,000 droplets with droplets traveling at up to 200 miles per hour. If a person is infected, the droplets in a single cough or sneeze may contain as many as 200,000,000 (two hundred millions) virus particles, which can be all dispersed into the environment around them [7].

When we cough or sneeze in our elbows, millions to billions of viral particles might find themselves in our elbows. What is the risk of transmitting those viral particles to others when we “shake elbows” with them? Obviously, that is an important point that deserves to be understood. Before we can fully understand the risk of infection associated with “elbow shaking” I think that it would be wise to encourage the public not to shake elbow, particularly when they use their elbows to cover their coughs and sneezes. It is important to emphasize that everyone should take the necessary steps to limit physical interactions with others while we are in the midst of this serious pandemic and the health experts are still looking into figuring out the SARS CoV-2.


  1. World Health Organization (WHO), 2020. Coronavirus Disease 2019 (COVID-19) Dashboard. , Accessed date: August 23, 2020.
  2. Chen, C.; Zhao, B. 2020. Makeshift hospitals for COVID-19 patients: where healthcare workers and patients need sufficient ventilation for more protection. J. Hosp. Infect.
  3. Wang, J.; Du, G. 2020. COVID-19 may transmit through aerosol. Ir. J. Med. Sci. 1-2.
  4. Jayaweera, M.; Perera, H.; Gunawardana, B.; Manatunge, J. 2020. Transmission of COVID-19 virus by droplets and aerosols: A critical review on the unresolved dichotomy. Environmental Research 188 (2020) 109819.
  5. Grayson, S.A; Griffiths, P.S; Perez, M.K; Piedimonte, G. 2016. Detection of airborne respiratory syncytial virus in a pediatric acute care clinic. Pediatr. Pulmonol. 52, 684-688.
  6. Liu, L.; Wei, J.; Li, Y.; Ooi, A. 2016. Evaporation and dispersion of respiratory droplets from coughing. Indoor Air 27, 179-190.
  7. Bromage, E.S. 2020. Coronavirus: The Risks – Know Them Avoid Them. , Accessed date: August 17, 2020

A sweet, gentle, honest, tender and nice soul is gone. COVID-19 hits home very hard.

For the last three or four months our world has been facing unprecedented challenges. We have been significantly changing the way we live and interact with each other. We will certainly have to keep those changes that recently happened in our habits, behaviors and lives if we want to seriously address this pandemic.

It is very unfortunate that some people have chosen to talk about all kind of conspiracy theories to try to minimize the impact of the coronavirus disease 2019 (COVID-19). Some folks are even attacking Dr. Fauci from all possible fronts. I can understand why they are attacking him. He, so far, has done an amazing job to counter-balance the craziness, lies, confusion and to some extent stupidity that is coming from the White House. Therefore he doesn’t sound like those crazy loyal White House staffs or officials who are willing to do everything to protect the president even at the expense of the general public.

Since the beginning of the pandemic we have been told all kind of lies:” ohhh it’s like the flu”, “it’s going to go away very soon”, “we will pass from 15 cases to 0 cases in a matter of days”, “coronavirus is a hoax”, “just another witch hunt”, yadi yadi, yada, yada. Those completely irresponsible statements were verbalized, tweeted, and boosted by the mainstream media minutes after minutes, day after day. It is really a shame to see how partisanship is playing a central role in the way we address a serious public health threat which is killing hundreds of amazing human beings everyday. Is that the best we can do? Really?

I am not a conspiracy theorist. I, actually, pay very little attention to what people have to say about the subject. I know, as humans, we never want to accept and deal with the predicaments that happen in our lives. It is just human nature. No matter what we are going through, we tend to feel better when we are told, or when we know that what we are experiencing is because of someone else who did something wrong, someone else who does not like us, or someone else who is the devil. Even if COVID-19 were the product of a conspiracy, one thing is factual, very clear and undoubtedly true: there have been more than 2 millions people infected world wide and about 165,000 who have passed away. If someone can prove to me that those numbers are fake, then I ‘ll decide to sit around and listen to those conspiracy theorists. I know that the number of deaths are real, and as a Medical Doctor and Public Health Specialist, my role and mission is to do whatever I can to care, protect and preserve human lives. I have always been paying attention to what is happening in my environment, I have always talked about what I like and what I dislike. I think that in respect to the COVID-19 pandemic I will be doing my best to be more vocal because there are a lot of people who are talking and providing misinformation and disinformation to the general public and to me that is really irresponsible and to some extent criminal. When someone say that COVID-19 is not an issue, it is an hoax, or just another way that a certain political party is trying to undermine another, I think that this whole situation is becoming extremely dangerous. I say so because we all know that there are family members who have been crying to the death of their loved ones who were not taking COVID-19 seriously enough because in the mainstream media and even the president of the USA told them not to take it seriously and everything is under control.

I think that being more vocal is the easy, straightforward, normal and understandable next step to take because COVID-19 has claimed the life of one of the nicest, more gentle, more tender and genuine human beings that I have known. COVID-19 has hit home. It’s one thing to be looking everyday at the number of cases and number of deaths and see how they are changing minutes by minutes, but it’s a completely different scenario when the numbers that you are looking at stop being statistics and become real life experience when your loved ones or people that you have known and valued for many years in your life are the ones reflected in the numbers. Yesterday was a terrible day for me. I received two bad news in about two hours. First at around 7:30 AM I received a text message from a friend who informed me that one of our former classmates in med-school in Haiti, who has been living in New York for a couple of years has passed away due to COVID-19. He was so young, only 43 years old. He was diabetic. Then, about two hours after I was informed that another former classmate from the same class and very good friend of mine, someone that I consider as a brother, was in the hospital (unrelated to COVID-19) with a blood clot in his brain. I was literally asking why, why, why and why? Why so much bad news for me in such a short period of time?

My friend who died of COVID-19 didn’t have to die. No one who died had to die. I don’t think that everyone understands the seriousness of the times that we are currently living. My former classmate, colleague and friend passed away in a hospital in New York all by himself. His family members could not even be with him. There might not even be funerals because of the constraints of the times we are living. Someone told me that the hospital might even refuse to give the body to the family. I am wondering if it’s a dream or nightmare that we are facing those times. My friend who is currently at the hospital is also all by himself. Even his wife could not be there with him. Where are we heading in this world with those new realities. We all should make an effort to take more seriously COVID-19. Regardless of where it came from, it is infecting and killing thousands of people and it is our duty and responsibility to care for everybody infected and affected by coronavirus.

I was watching on television some people protesting yesterday to force some governors to open their states. While I understand that many people are suffering financially, they are losing their homes, cars and other materials assets, I don’t think that we should let those material assets and to some extent literal greed blind us and lead us to make the wrong decisions. Until now not many tests have been done (just about 3 millions of tests were done for a population of about 330 millions inhabitants in the midst of pandemic whose infectious agent is extremely contagious and somehow quite virulent), out of all the people infected very few have been declared recovered. If we look at the numbers world wide, the mortality rate is about 6%. Out of those diagnosed only 25% recovered. What about the remaining 75%? We know that about 6% of them died, but where are the rest. Where are they? There is so little that we know about severe acute respiratory syndrome coronavirus 2 (SARS CoV2) [the virus that causes COVID-19] until now. Do the people who recover has immunity against the coronavirus now? Can they get re-infected? By refusing to take this very seriously are we setting ourselves up for a second wave of infections that can potentially be disastrous?

My former classmate, colleague, and friend is already gone. There is nothing that I can do about it. However I know that I can talk and act to try to convince as many people as possible to be more responsible and serious in the way that they approach and address the pandemic. If we are going to open everything is New York for instance, are we ready to manage the subway system appropriately? Usually in the train cars there are way too many people and there is absolutely no room to even breath. Are we really serious. That’s the way we want to move forward? What is the plan to re-open? What is the plan to prevent what happened to my colleague from happening again, and again. Until we can adequately answer those questions, I think we should just simply and humbly remain in lockdown because we know that the lockdown has prevented thousands, let alone, millions of infections. Let’s stop the greed so that we can save more lives.

In The Fight Against COVID-19, The Stay At Home Orders Do Not Apply To All of US.

We are currently living unprecedented times. If we are lucky enough to survive this scourge, many years or even decades from now we will be able to talk about those immemorial times to our grand-children, perhaps great grand-children and explained to them how we survive the scourge with stay-at-home order, shelter-in-place order, social distancing and all those other terms that are now part of our lexicon. For the majority of us, not a day passes by without referring to at least one of those terms. Our lives will have been for ever changed in a significant major way. We will be obliged to leave in 2019 all those habits or gestures that are believed to promote the spread of Coronavirus Disease 2019 (COVID-19). Besides handshake that I mentioned in an earlier post, I have been thinking of how in Europe people enthusiastically kiss each other on the cheeks when they meet. Sometimes Italians or French people get lost in the number of kisses that they should give each other ( is it one kiss, two or three?). Myself, I usually get lost in the number of kisses when visiting family members in Europe: when I think it’s just a kiss, they would say oh no, one more or even two more.

In order to considerably limit the spread of COVID-19, in many parts of the world the governments have been very firm and strict on preventing people from being in the streets if they are not essential workers. Depending on where you are living, the orders have been enforced with various degree of rigour. That observation in itself can explain to some extent the difference that we see in the data coming from various countries, cities, and counties reporting on the pandemic.

While in several parts of the world, many are respecting the stay-at-home orders and others have the responsibility to enforce these orders, we need to recognize and acknowledge the fact that for some of us the stay-at-home orders do not apply. In the midst of the complete chaos caused by COVID-19, there is an homeless population that is fervently and ardently fighting to stay away from the virus, stay alive, and stay warm. For those individuals, the home is a sidewalk or a space under a bridge. They are way less likely to get access to healthcare services if they were to be infected with the coronavirus.

In the USA, in New York particularly there is approximately 70,000 homeless people (including children). While there are some shelters trying their best to serve this population, every night there are about 5,000 to 6,000 people who sleep literally in the streets. At the onset of the COVID-19 outbreak in New York many shelters that were serving the homeless population closed their doors because there were a couple of cases diagnosed in those shelters. Therefore, there is now a higher number of homeless people sleeping in the cold, on the sidewalks or under the bridges every night. The stay-at-home order definitely do not apply to those amazing human beings. Besides the shelters being closed which cause more homeless to be in the streets, there is also the fact that in the USA 70% to 80% of people are just one of two paychecks away from being homeless. The economy has been hit severely by COVID-19, millions of people have lost their jobs, they don’t have any savings, and are forced to get to the streets. The stay-at-home orders do not apply to those folks either.

In my work implementing harm reduction programs in New York to serve people who use drugs, and those who are involved in sex work, I have come across some really interesting, very smart, and compassionate human beings who just happened to be homeless. Despite everything that is going on in their lives, despite all the negativity that constantly surrounds them, they always find the strength to put a great, beautiful smile on their faces if a provider is kind enough to make a nice joke.

I find it mind-boggling that in a state as rich as New York, in a country as wealthy as USA there are that many people without a place to call home. I find it despicable that in a nation considered the wealthiest in the history of the world there is such a high proportion of workers who are literally just one or two paychecks away from being homeless. Those are major issues that should be talked about more and more and ultimately addressed. I do not understand how many folks can be proud to talk about how strong the economy was before COVID-19 whereas those major issues have been around for too long. How do you define strong economy when there are so many that cannot even satisfy their basic needs. Those without a place to call home are not less human than the rest of us. They deserve quality healthcare services like anyone else so that they can tested and treated for COVID-19. Any plan being discussed on re-opening should include them. What are the steps that will be taken to re-open the shelters that are closed. On a larger scale, what is the plan to address the housing crisis that the “wealthiest” nation in history is currently facing. As states will be re-opening one major component of the public health approach to continue combating COVID-19 will be contact tracing in order to identify all the people that someone who is tested positive for coronavirus might have been in contact with. However, the conundrum is: how do you contact trace homeless people who, in the majority of the cases do not even have a phone whey they can be reached.

It is clear that the stay-at-home orders do not apply to the homeless people, nevertheless any plans to apply the lessons that will have been learnt through this overall situation should apply to them. Quality healthcare services apply to them. Having a place to call home is such an important determinant of health. To my knowledge, health is still a human right. Right?