What would an adequate COVID response look like?

Ok, COVID is a problem. What can we do about it anyway?

The problem is stark: we have unmitigated transmission of a deadly and disabling virus, in all public spaces, with zero plan to bring it under control.

We’re seeing millions of infections in each wave, and multiple waves a year; an unsustainable health burden on an already strained healthcare system.

We’ve got a student absence crisis, record worker sick days, rapidly rising disability, and the expulsion of high-risk people from public spaces.

And unfortunately, we have a public that is largely uneducated about and unaware of the problem, thanks to the tireless efforts of our political leaders and corporate media outlets who pushed for a “new normal” of forever COVID reinfections.

The first hurdle is making people aware of the problem. But beyond that, a second hurdle; often, once the risks of recurrent COVID infections are conveyed, the next objection is: but what can we do about it anyway? Surely you don’t want a permanent forever lockdown?

Well, I don’t. So what, in my wildest dreams, would competent public health bodies be doing to mitigate transmission of COVID, even years into a botched response with millions of people negatively polarized against collective measures?

1. Start from the top: acknowledge that COVID is airborne. Loudly.

   Educate the public about airborne mitigation measures and model them.

On April 30, 2021, the WHO officially acknowledged that SARS-COV-2 is a fully airborne virus. They did so quietly, without fanfare, on their website, without a well-publicized apology for the year they spent loudly claiming otherwise.

The embarrassment of this early mistake- costly and deadly as it was- has doubtless played a role in the subsequent inadequacy of communications around SARS-COV-2’s actual mode of transmission.

Droplet measures like surgical masks and social distancing were inadequate to prevent the transmission of COVID; both can reduce, but not eliminate, risk. Has the public been made aware of this? Have medical practitioners?

Official communications from representatives of the WHO and CDC tend to avoid mention of high-quality respirator masks entirely, if masks are mentioned at all. The importance of ventilation and filtration have never been properly explained to the public, certainly not by our politicians who continue to do nothing but repeat their treasured talking point, “COVID no longer controls our lives” while a thousand Americans lose those very lives to the virus each week.

In public, operatives from public health bodies do not mask, nor speak about airborne disease mitigation. Politicians certainly do not mask, even elected officials who quite clearly fall into high-risk categories, belying their claim that people are simply adopting the libertarian “personal risk assessment” approach to COVID. This refusal to mask, no matter the case numbers, no matter the risk factors, is a political choice designed to encourage the public to accept a lack of airborne disease mitigation. It pushes people to believe the virus is harmless, even as scientific research fails to support this claim, and while the CDC puts out conflicting guidance that large swathes of the public are high-risk.

Refusal to directly communicate 1) how COVID spreads 2) that it can be avoided 3) how it can be avoided while modeling mitigation, makes pandemic communications much more difficult for vulnerable people, activists and marginalized groups attempting to reduce disease burden in their communities. We should not be swimming against the current of public health officials’ poor pandemic hygiene.

2. Mandate airborne infection control in all healthcare settings

Of course, COVID is an international problem, and it’s critical that measures like indoor clean air and airborne infection control in healthcare are implemented globally. WHO has no legal authority to issue such a mandate; it can do little more than make recommendations. However, those recommendations have power, and as of now, it has failed to make them. Recommendations from WHO often form the basis of directives from regulatory bodies like the CDC.

The decision to claim that SARS-COV-2 was not airborne was politically motivated. There was no data to support this claim, only decades of bad physics in medicine and very strong financial and legal incentives to assume that COVID was not spreading through the air. It all comes down to the cost of rethinking medical care entirely, with an eye to airborne infection control.

I already wrote about the WHO’s recent attempt to both acknowledge COVID’s airborne nature while walking back their early-pandemic claims that, were COVID airborne, of course they would recommend proper airborne infection control measures.

Specifically, WHO Health Operations, Infection Prevention and Control Technical Team wrote in an April 2020 email to a group advocating for airborne precautions:

Would there be evidence of significant spread of SARS-CoV-2 as an airborne pathogen outside of the context of AGPs [aerosol generating procedures], WHO would immediately revise its guidance and extend the recommendation of airborne precautions accordingly

Well, COVID is airborne, and they have not immediately revised their guidance.

This continues to cost the lives of hospitalized vulnerable people every day.

It also contributes to public confusion about how COVID transmits, including among healthcare workers. Doctors and nurses are well aware that there is no airborne infection control in medical settings; their personal justifications tend to be either “because COVID must be mild” or “because COVID can’t spread that way.”

This is an understandable psychological response to watching their employers- hospitals and medical facilities- fail to implement measures to control the spread of airborne disease in a hospital. Either COVID must not be spreading that way, or COVID must be no big deal.

Education and mitigation practices coming from the top will speed the process of normalizing disease control and bringing down cases at an institutional level.

Like seeing public health officials masked, seeing doctors and nurses masked in hospitals with well-fitting respirators will also help educate the public about how SARS-COV-2 spreads, and confirm that indeed, COVID is still with us.

While there is no previous legal framework for patients to rely on, what medical institutions are doing is highly immoral if not explicitly illegal. They are failing to even attempt to provide proper infection control in hospitals.

Public health bodies should properly educate medical professionals about airborne infection control and mandate upgrades to hospital infrastructure that accommodate the existence of SARS-COV-2. Set the expectation that healthcare settings will be held responsible for healthcare acquired infections.

3. Legal and financial consequences for healthcare acquired infections

Currently in the US, many HAIs have to be reported to the CDC; that COVID does not, is a choice based on the reality that they are allowing it to spread freely.

From the CDC website on Healthcare Acquired Infections and the 2022 HAI Progress Report:

The Centers for Disease Control and Prevention (CDC) is committed to protecting patients and healthcare personnel from adverse healthcare events and promoting safety, quality, and value in healthcare delivery. Preventing healthcare-associated infections (HAIs) is a top priority for CDC and its partners in public health and healthcare….The 2022 National and State HAI Progress Report provides data on central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated events (VAEs), surgical site infections (SSIs), methicillin-resistant Staphylococcus aureus (MRSA) bloodstream events, and Clostridioides difficile (C. difficile) events.

The CDC itself states that preventing HAIs is a top priority, and it collects reems of data around other, more easily controlled infections. HICPAC, the CDC advisory body that recommends infection control measures has repeatedly come under fire from activists over the past several years as they attempt to shove through a new set of recommendations that incorrectly equates N-95 respirator protection with surgical masks and otherwise ignores airborne transmission of viruses.

HICPAC’s strategy for dealing with the entirely new paradigm uncovered by engineers and aerosol experts in 2021- because, bear in mind, the work of scientists like Linsey Marr showed that no viruses are spreading via “droplet” alone, the way scientists formerly conceptualized their transmission- is utter denial.

It would be too disruptive to decades of infection control norms to acknowledge that SARS-COV-2 came in like a wrecking ball to previous guidance; thus, HICPAC members are pretending they’ve never even heard of COVID. Watching their public facing meetings is bizarre; hours of academic debates where the pandemic isn’t mentioned, followed by 45 minutes of activists explaining that they are unable to access medical care, or that their loved ones caught COVID in the hospital and died. HICPAC members remain utterly stone-faced throughout these sessions and fail to acknowledge the comments at their next session.

Currently, Medicare has a program that reduces funding to hospitals with higher rates of acquired infections; COVID is not one of those targeted. Change this and watch how quickly hospital management goes from not understanding, to indeed understanding, airborne infection control. This is all a matter of financial incentives to hospital management, and those incentives must change.

Since 2020, incentives have stubbornly pushed healthcare institutions to ignore COVID to save the money it would cost to dramatically reimagine healthcare with top-to-bottom airborne infection control. How do you properly segregate COVID+ patients? When do you test them? How often do you test staff? Do you send COVID+ staff home? (Yes, you should, but currently the hospital saves money by not doing this).

We need to pivot from the early pandemic model of mandating individual behaviors (masks, distancing) to mandating outcomes (lack of viral spread in public spaces). That doesn’t mean a public space can never mandate masks, it means that masks must be part of a coherent strategy to prevent infections; this should also eliminate irrational mask rules (mask only before you sit down) and incentivize mask hygiene, education, and distribution. If a hospital loses money because of hospital acquired COVID, it is not merely incentivized to mandate masks. It is incentivized to mandate proper respirator masks, educate staff as to proper mask wearing, fit test masks, properly ventilate and filtrate, ensure that masks aren’t being worn on chins, test staff and patients, send sick staff home, ensure that meals can be eaten in a COVID-free, low-CO2 area, etc.

4. Legal and financial consequences for infections acquired in congregate settings, prisons, workplaces and schools

Continuing this theme; there is nothing particularly radical about the idea of legal repercussions for infectious disease via negligence in a workplace, school or congregate setting.

You can sue your workplace for infecting you with a foodborne illness if it was not following proper public health regulations. You can sue a school that doesn’t get your kid his epi pen in a timely manner. You could sue a retirement home with cholera in the water.

Therefore, world governments need to set indoor clear air standards, as well as assign culpability for the containment of outbreaks to employers, schools, prisons, etc., with government money available for infrastructure upgrades and a timeline for their achievement. If disease transmission occurs because indoor CO2 is high, because air filters weren’t turned on, because sick people were forced to work, that should be legally actionable the way dirty water and poorly handled food is.

All institutions- schools, workplaces, retirement homes, prisons- must have not only baseline protections like clean air, but outbreak plans. What happens in the event of a positive case? How is that handled, how is spread prevented? Government money, guidance and resources must be available to ease the development of this process.

Before Biden was elected, he promised to implement a new OSHA standard to protect workers from COVID infections. On January 21, 2021, the day after his Inauguration, he issued an Executive Order asking OSHA for revised guidance to protect workers from COVID-19. What resulted was both grossly inadequate and temporary. In June of 2021, OSHA issued an ETS - Emergency Temporary Standard- for healthcare workers only. It included guidance about social distancing, AGPs, solid barriers, and surface disinfection, though it was issued over a month after the WHO updated its website to affirm that COVID was not droplet spread.

It did, however, contain good guidance including screening for healthcare workers, sending positive workers home, reference to respirator masks, reference to HVAC and MERV-13 filters, but it has since expired. In the years since, OSHA has dragged its feet as workers’ groups like the National Nurses Union (NNU) lobbies for protections and industry groups like the American Hospital Association (AHA) lobby against them. If “COVID is here to stay” and “we have to learn to live with COVID”, why would worker protections from infection be temporary?

On the whole, workers were forced back into COVID-riddled workplaces with no new protections. A new OSHA standard should acknowledge the threat of airborne disease, make use of the many technological solutions for mitigating airborne disease, and outline the responsibilities of employers to both utilize available technologies, promote mitigation, and send sick workers home.

5. Comprehensive indoor clean air laws with specifications for upgraded ventilation, filtration, and other tools like Far UVC

I’ve already written about this in detail. The CDC has decent guidance, updated in May of 2023, about ventilation and filtration, here. However, none of this is enforceable without new legislation, nor does our current infrastructure meet these standards.

Ventilation norms and requirements must be overhauled. Currently, hotels and schools often have windows sealed shut; this is inappropriate for disease control and leads to dangerous levels of CO2 accumulation. All public buildings must be able to guarantee air changes per hour (ACH) deemed appropriate by aerosol experts, keeping CO2 as low as possible. Only MERV-13 or higher (HEPA filtration) effectively filters airborne virus from the air, so these must be standard.

I have only the basic knowledge of a layman; to learn more, you can check out this roadmap for national IAQ standards written by dozens of experts and published in Science.

Far UVC is another promising tool, and engineers should be consulted as to the appropriateness of implementing it in public spaces, particularly in schools, airports, hospitals, and crowded venues.

6. Work from home should be encouraged, conferences should be virtual where possible, flights should be tested.

Unwinding WFH in the midst of wave after wave of COVID was anti-science and self-defeating. Increasing the severity of waves and worsening spread in the community creates less productivity and more worker absence. Additionally, lessening the environmental impact of commuting and converting commercial real estate to residential should be priorities.

Governments, instead of pushing people back into the office, should be pushing in the opposite direction, for a sustainable approach to long-term remote work. This lessens community spread, environmental pollution, and local traffic, while creating more accessible jobs. Conferences should always have virtual options if they can’t be fully virtual. The carbon footprint of professional conferences is something I do think about a lot, but I digress.

Relatedly, yes, I believe people should have a negative PCR to fly. You do not have the right to get in a tube with a bunch of other people while positive for COVID, period. People need paperwork to fly. They need an ID to fly. They need a passport to fly internationally. It is expensive to fly. There should be on site, cheap, fast PCR or PCR-accurate testing at the airport, and you should need the negative to fly, like you need your ID and ticket. PlusLife tests are 5 Euros.

I had to PCR test to board flights to Mexico, Chile, Brazil, and Argentina in 2022 and nobody died. As a disabled person, it was the last time I was able to fly internationally, because I wasn’t forced to risk exposure. Testing has the added benefit of encouraging pro-social mitigation behaviors when people know they will have to test before flying.

7. Free masks, free tests, free vaccines, free Paxlovid, universal paid sick leave, and negative tests to exit quarantine

Expense should never be a barrier to practicing disease control. As usual, our governments continue to be penny-wise and pound-foolish, depriving people of the tools to keep themselves safe and incurring much, much higher expenses to the economy in terms of long-term health loss of workers.

As of now, volunteer-led radical mask blocs are attempting to fill in the gaps by offering free masks and tests to locals in need, but there is only so much that small groups of (often disabled and multiply marginalized) citizens can do.

We need free distribution of proper KN95 and N95 respirator masks, as well as tests; ideally tests that work well. Currently, the government sends out the odd packet of 2-4 rapid tests; RAT tests are 28% accurate on day 1 of symptoms. We need to get more tests and more accurate tests into the hands of the public, for free. Then we need to allow people to stay home until they test negative.

The CDC has unscientifically reduced the COVID quarantine several times until it has become functionally non-existent; this was done not to effectively control disease, but to appease employers. People with COVID-19 should leave quarantine when they have tested negative on two tests, 24 hours apart. Period. Not before. A positive test = viral load = contagion.

OSHA standards that penalize employers for spread between employees would incentivize the provision of proper sick leave. I do understand that the government, after failing to control COVID for so long, cannot shift the burden of disease control overnight to individual business owners. There needs to be a long period of infrastructure upgrade, education, resource distribution, perhaps even tax incentives for proper pandemic management and airborne infection control. But overall, incentives must align to push individual institutions toward infection control and away from infection maximization. The government must continue to provide support, resources, and education, while building a framework for regulation and financial disincentive as well.

Vaccines must be free. Paxlovid must be free. And in an ideal world, in a world that truly wants to end this pandemic, and all pandemics, healthcare must be free.

8. Education

Education can take many forms; even the implementation of proper airborne infection control in hospitals is a form of education. It educates the public “here is how you halt the spread of COVID” and “yes COVID is still here” and “yes we take it seriously because it can kill”. Currently, hospitals and medical professionals, at the behest of the WHO and CDC, are communicating the opposite.

But in addition to the education provided by modeling airborne infection control, wearing masks, instituting infection control, implementing legal consequences for infections, setting a new OSHA standard for workers, etc., the public needs direct, honest communication about the health risks of COVID.

This means talking about the risk of Long COVID that accompanies each infection without purposely undercutting that messaging by then loudly reassuring people “but it probably won’t happen to you.” It means explaining COVID is a multi-systemic disease, not just a respiratory virus. It means explaining that COVID carries long-term health risks that outlast the acute infection. It means explaining that COVID variants are excellent at evading immunity, meaning they learn to outsmart our body’s protection via vaccine or previous infection; that’s why you must get boosted and layer your precautions.

Of course, the above is only an overview of prevention. We need another coordinated, funded, communications and research campaign to handle the Long COVID crisis.

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In the fantasy world where tomorrow, we can build an ideal pandemic response from the ground up, I see several major switches that would need to flip.

The first is that the culture of silence and denial among leadership would have to change to one of education and communication. Right now, state representatives are deliberately avoiding mention of COVID, while propagandizing the safety of infection and/or the end of the pandemic by refusing to mask. It is hard to imagine how successful a pandemic response might be if public officials were actually trying to end the pandemic. We quite literally have public health and political and media figures working to hide three pieces of critical information: public knowledge of the virus, public knowledge of mitigation measures that would reduce viral spread, and public knowledge of the severity of the virus (which would motivate desire to reduce viral spread).

On the one hand, that is a terrible and depressing place to be. On the other hand, it tells us that we might better control COVID through public behavior alone, if the public were given information and tools instead of purposely obstructed from accessing either. We have a lot of room to grow.

The second would be the construction of physical infrastructure to deal with the existence of very contagious, very common, highly disabling airborne virus that is currently circulating in all public spaces. If we have to “learn to live with” COVID, let’s learn to live with an airborne virus by cleaning the air.

The third would be building the legal infrastructure to enforce and hold accountable a failure to implement said physical infrastructure, along with other disease control measures. Patients should not be infected in hospitals. Workers should not be forcibly infected at work. Prisoners should not be forcibly infected in prisons. Kids should not be forcibly infected in schools. Let’s drill down and prevent transmission in congregate settings, with accountability.

COVID control essentially came to an utter halt because our system was not designed to control airborne disease. Our governments did not want to pay to do it. Our governments did not want to explain that they did not want to pay to do it. But this is 2024. We have technology we haven’t even begun to deploy in the fight against COVID, all because we’re too proud to admit we’re still fighting. We have not even scratched the surface of what would a pandemic response that acknowledges the airborne nature of COVID could achieve.

The introduction of the vaccines in early 2021 appeared to our governments like a “get out of jail free” card. They thought they could grab onto it, induce broad herd immunity, and get back to normal without ever acknowledging or paying for clean air. But that isn’t what happened, and now, our lack of mitigations continues to rapidly produce new variants that harm the efficacy of our vaccines.

It would’ve been nice if the vaccines were all that were needed to end the SARS-COV-2 crisis. Since it isn’t, we need our leaders to stop doubling down on their failed strategy, accept reality, and start building a long-term approach to ending this airborne pandemic, as well as avoiding future ones.

The problem underlying all the current failures is that, quite simply, our government is not trying to end this pandemic. It is trying to hide this pandemic. And you’re not going to solve a problem you won’t acknowledge.