"Learning to live with COVID" means upgrading air quality, now

This level of illness is unsustainable. Fortunately, basic measures can drastically reduce viral spread.

As we hit the second largest peak of COVID cases ever, with an estimated 1.5 million cases occurring daily in the US, those who want to “learn to live with the virus” should take stock. It’s clear that “learning to live with” COVID, as it stands currently, involves absolutely no learning and significantly less living, with current US deaths above 2,000 weekly and projected to continue rising for another 3 weeks at least (as death counts do not peak until 3 weeks after case counts).

What have we “learned” about the virus since 2020 that we are implementing? We learned that COVID is airborne, so what new indoor air quality measures have we introduced? We learned that the vaccines wane quickly and the virus mutates even faster, so how are the rates of annual vaccination going? We learned vaccines don’t prevent spread, so how are we mitigating spread? We learned post-COVID health effects are serious and common, so how are we adapting our approach to COVID infection with this knowledge?

If your answers were none, badly, not at all, and zero, congratulations. Your prize is annual reinfection with a vascular disease that causes heart, brain, organ and immune system damage, free of charge. (Some restrictions apply. Free infection does not include diagnosis, lost wages, cost of associated healthcare, cost of long-term disability, or other associated costs. Each item sold separately. Visit a COVID distribution center- literally any public space- to redeem.)

COVID denialism has reached- forgive the pun- a fever pitch. Parents report their children’s continual illnesses and attribute them to a three-year-old lockdown instead of documented post-COVID immune harm. The public notes the spike in cardiac events and sudden death but attributes them to vaccination instead of the novel virus proven to harm hearts. The media cycles through COVID’s pseudonym of the week, the Festival Flu, the Summer Flu, the 100 Day Cough, the ever-popular Mysterious Virus. Tiktok videos emerge of bewildered people reporting never-ending sickness- commented on by thousands more experiencing the same. The word COVID isn’t mentioned.

And don’t look for airborne infection control in healthcare settings. Hospitals, too, are handing out complimentary COVID infections like lollipops to anyone who dares to seek care. Vulnerable patients are weighing their need for medical attention against the possibility of being infected. Let’s recall that CDC guidance has always stated that COVID is dangerous for vulnerable groups. The danger hasn’t changed; only the degree to which people care.

Of course, the public can’t be blamed for their inability or unwillingness to remember what COVID is or what it can do. Many of them were either never told about COVID’s risks, or were assured that COVID “became mild,” right around the time COVID’s purported mildness became important to Biden’s political future. (Ron Howard narrator voice: It didn’t.)

The purposeful and inaccurate minimization of the SARS-COV-2 virus has, ironically, occurred against the backdrop of thousands of increasingly concerning studies. Were the results of these studies communicated to the public, we wouldn’t see the purported “COVID fatigue,” “pandemic fatigue”, and “mask fatigue,” all of which were invented and encouraged by a Biden-apologist press that pushed the failed “Back to Normal” strategy years beyond its expiration date. When people are given proper information about their risks, from real authority figures (not just Substacks and researchers on twitter), they want to protect themselves and their loved ones. It’s only when they are told that COVID presents no threat, and mitigations are socially stigmatized, that they relax their protocols.

In other words, minimization has cascading consequences in the community. People who are told “COVID is a cold” or “COVID is the flu”, (both Trump-era talking points repurposed for the liberal crowd), will not get vaccinated every fall. They will not wear masks. They will not test before gathering. And they will not advocate for institutional mitigations- like new clean air standards. This lack of advocacy- the silencing of demands that governments take responsibility for public health- is, of course, the only real goal of minimizing COVID.

My last article tracked the progression of the “back to normal” vaccine-only pandemic strategy from “you won’t get COVID” to “you will get it every year and every infection comes with a risk of disability, but just assume it’ll happen to someone else”. After it published, people asked about what my pandemic strategy might look like- did I want to go back into lockdown? Did I want to force everyone to wear a mask forever? Did I want unvaccinated people to be put into camps?? (No, only in a few places, and that is an epidemiologically terrible idea.)

So what should living with COVID - a highly contagious, fully airborne disease with a compounding, serious risk of long-term disability- look like?

The most under-discussed tool in our toolkit is indoor air quality improvement.

The topic may not be sexy, but we must foreground it in the conversation about COVID. Many people are politically polarized away from masking and the anti-science folks at the top are making it incredibly difficult to convey the benefits and importance of masks. Prioritizing long-term infrastructure upgrades- meaning increased ventilation, filtration, and indoor CO2 monitoring- will make it more difficult for anti-maskers to harm their neighbors with forcible infection. One-way masking is always inferior to two-way masking. However, one-way masking in a high air quality environment, with frequent air changes per hour (ACH), high-level filtration (MERV 13 or higher, HEPA filters) and CO2 monitoring will be significantly superior to one-way masking in a low air quality environment.

This strategy- of mandating cleaner air in all public spaces- would not just improve the individual risk of a single person entering a single space. It would have compounding benefits by significantly reducing how many people each COVID infected person is able to infect. This number- the expected number of additional cases generated by a single infection- is known as the “basic reproduction number”, or R naught (written as R₀). The R₀ is often thought of as a static measure that conveys the contagiousness of a disease- but it’s actually a measure of the way the disease is interacting with the public. Improving air quality universally will lower COVID’s R₀ and begin to bring down disease burden generally. This, in turn, makes it less likely that there are infected people in any indoor space to begin with.

A nice side effect is that, in the process of mitigating COVID, we will significantly reduce the spread of all other airborne viruses- which, it turns out, is most if not all of them. Even our imperfect masking and pseudo-quarantines eliminated a strain of flu in 2020; most viruses are significantly less contagious than COVID and many might be eliminated as a side effect of mitigation efforts.

Aerosol scientists are much better equipped than I am to design the details of indoor air quality (IAQ) policy, and they should be commissioned to do so. The Center for Health Security and the Center for Public Health Law and Policy at Arizona State University put together a Model Indoor Air Quality Act for State Legislatures, which would create IAQ Advisory Councils to advise the state and Governor. Additionally, indoor air quality experts must work with the CDC on infection control guidelines.

While I’m not an aerosol scientist, I have learned enough to give a broad overview. More air changes per hour means better ventilation. Even opening windows can significantly improve indoor air quality, making it an important, low-cost mitigation to communicate to the public (noting, of course, that no PSA will be effective at mitigating COVID without honesty about the risks to post-COVID health.)

CO2 is a proxy measure to estimate how good ventilation is- it estimates how long exhaled breaths are hanging in the air, contaminating it. Ideally, the lower the CO2 the better. 300-500 ppm, or ~400 parts per million, is outdoor air quality; the higher it goes, the worse it is. Above 1000 ppm, cognitive performance begins to decline. Parents are investigating their kids’ schools’ indoor air- and recording CO2 levels as high as 2,000, 3,000, 4,000 ppm in classrooms. In fact, citizen volunteers, using a CO2 monitoring device called an Aranet, are documenting poor air quality in many public spaces. Sadly, schools are consistently recorded as having some of the worst air quality in the community.

Do we really think parents would be happy with this critically poor air quality if they were aware? Can you imagine the community level reduction of illness if schools alone reduced their levels of viral spread?

Filtration is another component of clean air- it is not the same as ventilation and CO2 levels are not a proxy measure to determine filtration. Ventilation exchanges indoor air with outdoor air; filtration cleans it. You can have high CO2 and good filtration, as is sometimes the case on planes, which do have HEPAs. High quality filtration can be provided by MERV-13 or higher filters and HEPA devices, removing not only COVID from the air, but other viruses, bacteria, molds, allergens, and pollution.

As of now, guidelines put out by ASHRAE for residential buildings recommends MERV-6 filters or higher, although many homes still use MERV-4. These filters are not sufficient to filter viruses; MERV-13 or higher are. We need to start thinking about making our infrastructure pandemic-proof and understand that the cost of filter upgrades will far outpace the long-term savings to society. After all, even if continual waves of COVID weren’t a completely unsustainable social burden (it is), we must assume we will continue to encounter new viruses. Wouldn’t it be great to be prepared for the next one? If, when the next pandemic hits, we already have a national standard of MERV-13 and HEPA filters, indoor CO2 below 800 ppm, and a population well versed on airborne transmission and the types of masks that work?

Upgrading air quality is quite simply a slam dunk for public health- and will save exponentially more money than it costs. Frankly, it’s wild that it’s taken us this long to talk about filtration and ventilation as critical components of a successful pandemic response. Clean water has been critical to reducing waterborne disease like cholera; why should we think about airborne differently?

Clean air will not be the only component of a successful public health strategy. Masks must be mandatory in healthcare and hospitals- this is not up for debate. Vulnerable people must access medical care, medical care often involves the removal of masks, and infection control is a primary responsibility of health facilities. The argument that hospitals can stop mitigating because only weak people die from hospital-acquired infections is antithetical to the Hippocratic oath and every tenet of modern medicine. It is indefensible and this period in medicine will be remembered with shame.

I also would like to see masks return in pharmacies, on planes and public transit, and in supermarkets while we get clean air implemented, although I understand how politically difficult four years of misinformation and anti-mask propaganda has made such policy. While I do advocate for masks in these spaces, public education- coming from the US Government, the CDC, our President, the media, and prominent figures- is just as critical if not more critical in normalizing and promoting wearing proper masks.

In the era of mandates, we saw many people wearing ineffective masks, wearing masks below their noses, wearing masks on their chins, pulling them off to eat, and more behaviors that lessened universal masking’s impact. People who are properly informed that they have a high risk of becoming long-term disabled by a virus currently circulating at a high level are much more likely to wear a good mask (KN95 or N95), wear it properly (over the nose and mouth, testing for fit), and keep it on throughout their day. Many people, when properly informed that they can seriously harm or even kill others with asymptomatic transmission, will be similarly motivated to mask properly.

It’s true that over the past several years, some people proved that they simply don’t care about others and would prefer vulnerable people to die than to be mildly inconvenienced. But many people are simply badly informed. In my experience, when people know better, they do better. All of the close friends that I see on a day-to-day basis are now consistent maskers because they are informed. My parents and brother have never had COVID because I never stopped keeping them up to date about emerging COVID studies. I know people who have recently returned to masking after finally understanding that the virus is mutating around vaccine protection, or after being asked to mask in leftist spaces. Most often, the explanation I hear from those who won’t mask is, “COVID isn’t dangerous anymore.” To me this implies that an understanding of the dangers of COVID and post-COVID could lead to changed behavior.

Keeping COVID mitigation tools accessible and free is also critical. One of the most craven and disgusting efforts of the see-no-COVID Biden response has been the clawing back of free tests, masks, treatments, and vaccines. All of these tools more than pay for themselves by reducing virus in the community, reducing illness, reducing healthcare burden, reducing short staffing, reducing student absences, reducing long-term disability, and more. Tests must not only be free, but they must be accurate. Sending out a handful of rapid tests once a year is so insufficient as to be insulting- especially since rapid tests are notoriously inaccurate, and official guidance recommends performing three RATs on three consecutive days to confirm a negative test. For this reason, we should have accurate, PCR quality tests available on demand, for free- you know, like people who visit the President automatically receive.

Encouraging people to use our “tools”- masks, treatments, vaccines, and tests- means not charging them for the privilege. People who mask, test, get vaccinated and access treatments are following public health advice, protecting the community, and saving the government money in the short and long term; for this they deserve thanks, not to be taxed. Particularly not in a country where minimum wage isn’t sufficient to afford a one-bedroom apartment in any major city. Punishing socially beneficial behaviors makes no sense.

Paid sick leave also benefits workers, employers, customers, families, everyone, everywhere. Having a contagious, ill person in a workplace- or depriving them of their paycheck for needed time off- does not produce more economic benefit for the business or the country. Rather, it exposes more people unnecessarily and exacerbates staff shortages, as we’ve surely seen over the last several years. Of course, for leftists, this isn’t just an economic argument; workers deserve to rest and heal because it is a basic right. Watching upper-middle class progressives with paid sick leave abandon working class people to lost income and worsening health outcomes has been depressing. I’m hopeful that- with yet another massive wave cresting- people are beginning to notice how unsustainable this all is, that there is no immunity to COVID nor an end in sight to reinfections.

Of course, professional class people would also benefit from federal measures to address COVID; remote work options should be both promoted and maintained, not dismantled. Aside from the obvious epidemiological upsides, the ecological benefits of reducing commuter traffic were drastic in the early days of the pandemic. The left should hold firmly to the progress made and note that flexible workplace policies also empowered marginalized groups, in particular disabled people and single mothers.

I’ve written in the past about the existence of COVID-safe spaces for the super-rich, the White House being one, Davos being another. It’s clear that where there’s a will, there’s a way, and when lives are valued, they can be protected. COVID, more than a biological problem, is an engineering and sociological problem. The good news is while there’s no biological solution to such a new and dangerous virus, there absolutely are engineering and social solutions.