On the ongoing (yes, really) pandemic

As someone who is immunocompromised, I’ve been advised by my government that it’s up to me to protect myself from COVID-19; they and my community will do next to nothing, not even requiring masks in healthcare settings. (Do I sound angry? Good. I am angry. I should not have to risk permanent disablement or death to visit my primary care doctor, but I do. Also, to vote, and any number of other things. Society is trying to leave me behind, and I am furious about it.) So it probably makes sense for me to write down what I’m doing to protect myself, both to share with others who are in the same boat I’m in and with anyone who might ever want to spend time with me in-person. Or, I suppose, with anyone who does NOT want to spend time with me in-person—I’m actually very easy to keep away, these days.

Mandatory IANAD note: I’m not a doctor, an immunologist, or an epidemiologist. Nothing here should be considered advice, unless it matches what your own doctor or health organization is telling you.

As far as I can tell, there is no truly zero-risk way to share the same space with other people, unless everyone has quarantined beforehand. 1) Outdoors, 2) in a small group, 3) maintaining reasonable levels of personal space, 4) with everyone wearing a high-quality mask is practically zero and something I did without hesitation with various friends in Pittsburgh. Obviously, we were all vaccinated and boosted.* High ventilation (1), no crowding (2 and 3), and everyone masked (4): that’s the short version of this post and the way to get me to show up to something. There is also a time factor—I will go into an unsafe place for a very short amount of time in a very good respirator, if needed, but as the time increases, so does the minimum mitigation I’ll accept. But for anyone who is interested, the rest of this post is about my reasoning and some of the mental math I constantly go through to calculate risk.

It’s less about acute COVID-19 for me

I would argue that, even aside from little things like “caring about the most vulnerable among us,” we should all still be working to avoid infection. Long COVID is disabling, and from a practical standpoint, most of us need to be able to work to pay our bills; the unlucky folks who end up with the chronic exhaustion piece of it … can’t. We also need brains and hearts, Long COVID can wreck both. Numbers vary by study and by definition of “Long COVID,” (“post-acute sequelae of covid,” or “PASC”/”PACS”, if you want to search the medical literature yourself) but 20% still seems to be the accepted percentage of the general population who will end up with long-term health effects after a COVID-19 infection. Some studies have suggested that markers of an existing autoimmune disease correlate with a much higher risk of developing PASC. Or, OK, it’s worse than that: “Regarding specific pre-existing conditions, the analysis indicated that asthma; chronic constipation; reflux; rheumatoid arthritis; seasonal allergies; and depression/anxiety were associated with long COVID.” So, uh. I expect my risk is probably much higher than 20%, if I catch COVID-19, and perhaps you should consider whether yours is, as well.

Also, take it from me: being immunocompromised really sucks. So it’s worth being aware that COVID-19 damages the immune system in ways we are still trying to understand.

Also worth noting: people are still dying from acute COVID-19 as well. It’s very difficult to get the actual number, anymore—I’ve seen estimates of a couple hundred a day?—but as of the time of writing, whatever that number actually is, in the US, it is up 9.1% from last week. These are people who are up to date on their vaccines, in many (most?) cases. Dying from a preventable illness, because the general public got tired of mitigating for it. It’s infuriating.

So, how am I thinking about mitigations?

Let’s begin with the fact that COVID-19 is primarily an airborne virus; it can theoretically be spread through fomites (virus material deposited on surfaces), but airborne, respiratory droplet, and direct contact are generally considered to be the main transmission pathways. I don’t worry overmuch about fomites: I’ve worn a respirator and kept my car windows open to do it, but I’ve bought food and coffee from drive-throughs with minimal concern for safety (beyond the standard “boy, I hope there’s no food poisoning” thing, of course). And, although I’m a huge proponent of hand-washing—it’s pretty much the first thing I do when I get home, for instance—I roll my eyes and glare at every COVID-19-themed sign or website that reassures us about “sanitized surfaces” and “hand sanitizer provided,” doubly so if masks are optional and triply so if the words “ventilation” and/or “air filtration” never show up.

In the next few paragraphs I’m going to make it sound like I don’t believe in respiratory droplets, but I absolutely do. In fact, because the eyes are particularly vulnerable, I wear a brimmed hat and glasses that I don’t need (they block blue light, but that’s it) when I go somewhere where people aren’t masked, especially if I’ll be in close proximity to another person. I felt weird about the etiquette breach inherent in wearing a hat to the doctor’s office last week, so against my better judgment, I didn’t. But to my vaccination appointments, blood draws, and other indoor things? I do everything I can, short of wearing safety goggles, to keep droplets out of my eyes.

Unfortunately, the whole “six feet” thing and focus on droplets from early-pandemic have led a lot of people to misunderstand what is meant by “airborne” — I like this video a lot (except for the part about surgical masks; please wear a KN95 or better respirator, there’s no shortage anymore), and if you’re someone who is comfortable taking more risks than I am, it goes into ways to mitigate those risks through CO2 monitoring and other measures. Anyway, I bring it up to say that they use the same model as I do for understanding airborne transmission: if someone in a room were smoking a cigarette or wearing too much cologne, six feet wouldn’t be magic for very long, right? It’s the same with airborne viruses.

And just like secondhand smoke, your virus dosage increases with the amount of time spent in the room, both by the smoker and by you. Even I, with a nerfed immune system, would not come down sick with COVID-19 if only a single viral particle entered my system. Dosage matters. More viral particles means more chance of being sick, and once that threshold is crossed, more virus generally means a worse illness. This understanding of dosage and the metaphor of the cigarette smoke are also part of why I let down some of my guard outdoors; a lifetime of allergies and years of pre-COVID immune suppression have taught me to avoid standing downwind of the group, so the mask is almost just a bit of extra insurance, as long as there aren’t too many people around. (Similar reasoning to the USB-powered fan I used to keep at the reference desk during flu season; I wasn’t hot, I was keeping people from breathing on me.)

Also like secondhand smoke, virus-laden air can make its way around any gap between your mask and your face. You need to be breathing through the mask, not around it, for it to protect you and those around you. Surgical masks are great for droplets; they are significantly less useful for aerosols. If you want to be environmentally friendly and potentially also safer, consider upgrading to a reusable respirator and taking the time to learn how to test its fit:

• My current choice is this one. I chose it based on a fellow educator saying it was easy to speak through and kept her safe while teaching in-person. I thought the purple color would come across as friendly, but because multiple people have asked about my “gas mask,” I’m considering switching to something more normal-looking.
• Some friends swear by the Flo Mask, which also comes in childrens’ sizes(!). The standard adult mask is KN95 certified, and the Pro mask has been NIOSH tested to 99% filtration. I am very interested in that one.
• If you have a face that it fits nicely onto, the original Envo mask is nice because you can add a cover, thereby protecting the filter from rain and from animals licking your face (look, we went to pet some goats at a farm a couple of weeks ago, and it’s a thing). It could also be decorated, which pleases me. The original doesn’t work well with my face shape, though; I feel like I lose my seal when I smile, in part because there’s only one attachment point between the elastic and the mask. It does seem to work for my spouse, and it is his mask of choice these days. I would be really interested in their new “pro” design, which has two attachment points, but the N99 is only available with an exhalation valve, which always makes me feel like a jerk to take advantage of, even when nobody else is masked. (Worth noting: the original Envo mask also has an exhalation valve, but I put the plug in when I bought it and immediately forgot there was even an option. You can’t tell immediately by looking if an Envo mask user has the plug in or not, which is non-ideal.)
• When I’m in a lower-risk setting (outdoors), I sometimes go with a Cambridge mask, which I understand to be roughly N95-equivalent. I really like the color options and the fact that they just look … friendlier? than your average reusable respirator. (Down side: anyone who knows what they’re doing might assume you are only wearing a standard cloth mask and not trust you.) If you buy one of the valved ones (useful for crafting and dusty chores and wearing on smoky days), you can modify it by putting a sticker (that they’ll sell you, even) over the valve, and a second sticker goes on the outside to say the valve has been disabled. I have a mix of valved and non-valved. The big down side is that they are really hard on my ears after a couple of hours, even with the included band that goes around the back of your head. A friend posted directions (sewing required) to modify them for elastic around the back of the head, and I’m planning to do that to some of mine. Still planning, yes; the directions are more than a year old, now, and I haven’t done it yet, but I really want to! (Also, I lost the directions, but if anyone needs them, let me know, and I’ll get them; I’ll edit this and also put the link in the comments.)
• Sumana Harihareswara (whose post I made sure to wait and read until after I’d written my own) has, fascinatingly, almost zero overlap in her list. There are several really good options there, though! Overall, Sumana accepts a bit more risk than I do—and reasonably so, given that she has a different risk profile, career, and daily environment. I appreciate the thoughtfulness of her approach and generally agree with her conclusions. (Sumana, if you see this, you might consider adding “hydrate beyond all reason—no really, even more than that” to your list of what to do in case you get COVID-19, but yeah, that’s a great list, and I’ll look at it again should I be unlucky on one of my required outings. For my part, I’m going to very quickly order some Enovid, which I hadn’t heard of before now!)

It’s worth noting that I am generally considering an N99/P100 a minimum to go indoors, at this point, and being very paranoid about the fit, because one-way masking is insufficient to fully protect me, especially if I’m stuck in an unsafe place for more than a few minutes; but it is the best, apparently, I am going to get. I mention this in part to raise awareness and empathy because so many workplaces—thankfully, not mine—are bringing even their remote people together in-person, and combining this with the standard academic and corporate “you can mask but you can’t ask others to” would make any in-person work event of any length not only dangerous for me, but actively tortuous. In the best case, it’s outdoors, and maybe the wind is steady, so I can head far enough away and upwind for long enough to have a snack or a drink when my body needs it, without having to leave altogether. There will be too many people for me to really let my guard down, all packed into whatever shelter is provided, and being one of the few wearers of a respirator will set me apart in an unpleasant way, but it’s still a best case. In the worst case, it’s indoors, and I can’t even really risk a sip of water unless I leave the meeting space, possibly the entire building, altogether. My coworkers will not be getting the best of me when I am actively miserable and anxious, and I will not be getting any of the benefits nominally attributed to in-person gatherings.

So if you’re in a leadership position and suspect anyone in your organization might be immunocompromised, please do not do this to them! Seriously! Please consider not doing this even if you don’t think anyone has ever been ill in their lives; COVID-19 is still no joke, and human toll aside (sigh), it is not in your organization’s best interests to have a COVID-19 outbreak, with up to 20% of your team suffering long-term complications.

(A note to my coworkers, if any happen upon this: if I need to come in and kick a server, at some point, that’s a short enough visit that the above doesn’t really apply. I will be wildly uncomfortable the whole time I’m indoors, yes, so I will do what’s needed as quickly, with as few people around, as possible. And if anyone wants to chat I will drag them outside to do so—and then probably have a really pleasant time, because I like my coworkers. Like I’ve said, I’m open to showing up and walking around outdoors on campus to chat with people on nice days. I actually considered attending the food truck event, but thought it might be just a bit too crowded, and the only way I could eat was to be far away from everyone, which seemed anti-social, so I skipped it.)

Also, bless the makers of that video I linked for mentioning that the virus continues hanging around in the air after people leave the room! When I’m forced to do something in-person indoors, like a doctor’s visit, a blood test, a vaccination, getting my government ID, etc., I try to do it first thing in the morning, in the hope that the previous day’s virus has been cleared by the HVAC system. Anyone who knows me knows I’m not a morning person, so yes, this is unpleasant; but only having the virus particles of the people in the room with me now, as opposed to the particles from multiple hours’ worth of visitors, is worth the extra suffering to me. I’m grateful to the video makers for including it because, out of all of my attempted mitigations, this is the one that is the least understood by everyone I interact with, it seems. The idea of air lingering is apparently just not intuitive to most folks.

So what does life look like, practically speaking?

Until we’ve got a cure for Long COVID (and ideally a better handle on the immune-disruptive effects of acute COVID), I am kind of locked out of society, as is my spouse. I can’t go to a show, unless the venue requires masks and has awesome (documented!) ventilation, which none do. No parties, no in-person conferences, no pet stores, no coffee shops (gosh I miss coffee shops). No hotels (doors along a hallway and shared ventilation), but if there were a family or friend emergency, possibly a motel (door open to the outdoors and a crappy single-room air conditioner) or unattached rental cabin/shed/ADU could work. Obviously, I don’t fly or take the train. I’ve had to work outside the lines with my local library, to be able to borrow things from them without going indoors. Target, Lowes, and Hannaford (local grocery chain) all offer curbside pickup, two of them for no extra charge, so I use all three. I’m not sure my conscience would allow me to send my extremely anxious bird into the vet alone, so I’ll go in with him when I stop putting off that appointment, which is now very overdue; my spouse went in without me when our chinchilla needed care, although I rode along for the enrichment opportunity of seeing a new part of Maine.

Speaking of Maine, because of the pandemic (and the timetable for our move, which was incredibly tight) we made the decision to buy a house sight unseen. I mean, we did a video tour with a Realtor we trusted (she’s so great!), and we ordered every inspection under the sun, but we didn’t step foot in the house until more than a week after we’d closed. The alternative was finding a rental that would either be too small for two mostly-housebound adults or too expensive for the one salary we’ve got right now; and, crucially, we would be forced to allow the landlord and eventually any potential future renters in, without having enough power to require masking. It was a huge risk, and we are so lucky that we ended up in a house we actually like very much.

The drive up here was a little bit fraught, because of course there were no mask mandates in place anymore; we brought enough food and drink for ourselves, we drove very carefully, and we only ever went indoors long enough to use a restroom. We went to gas stations rather than restaurants for that, figuring that at least people wouldn’t be lingering there, sending virus out into the air through a whole meal.

We go outdoors when we can, of course. There’s a really good bike path nearby, and I waffle back and forth on whether I need to mask while doing that. (There is a whole sidebar here about invasive caterpillars with toxic airborne hairs, but this is already a long post.) When we have walked the bike path I generally have not masked, but on any walk I always hold my breath (subtly) while people pass, until I’m sure the air is clear. My favorite beach (yay, Maine, I have a favorite beach!) is starting to get crowded, but there’s always a good deal of wind. I’m still trying to determine how many people have to be there before I’ll decide it’s unsafe. The bike path has a walk-up ice cream store beside it, which is nice (and a good reason to remember our masks!). We also visit food trucks as long as there aren’t long lines, which is pleasant, doubly so if we take our meals to the river front to eat. We visit local parks and Audubon preserves to see wildlife, and we feed birds in our own yard, as well. It isn’t quite the life some people are living, but it isn’t pure misery, either.

On the more serious side, I’m avoiding some necessary medical interventions and diagnostic appointments for as long as I can, despite the risks inherent in skipping those things; and when I’m forced to go to a doctor in-person, it is anxiety-inducing enough that my blood pressure readings are through the roof (happily, my doctor accepts my at-home readings). I’m dreading getting my Maine driver’s license, because of course you have to have a mask off to get a photo taken for that. I can’t speak at my town’s meetings, because they are in-person with only a stream (no interaction) for virtual attendance.

So, yeah. I’m angry. I get even angrier when people talk about the pandemic in past-tense, or when they act like caution about COVID-19 is irrational; being patronized and gaslighted infuriates me anyway, and when it comes from a place of ignorance (most people) or capitalistic fervor (the people in charge, many of whom absolutely do know better), it’s that much worse. I get really mad when organizations hold in-person conferences (full stop), though building a robust hybrid option mitigates a little of my frustration; still, right now, I maintain that any large organization choosing anything short of virtual-only is being pretty exclusionary across [dis]ability and class lines, in addition to (in the case of organizations also serving a large geography) being indefensible from a carbon standpoint.

In short, I understand people’s desire to socialize “like before,” and I get their drive to ignore risks in order to forget about times that they have found to be difficult. Given that it comes at the expense of my participation in society, and that this collective willful ignorance keeps making the virus worse… Well, my empathy does run a little thin at times.

* If you aren’t even taking that minimal step of being vaccinated and boosted (assuming it’s physically possible for you), I’m not sure why you are here, reading this, because it would seem you do not even agree that we live in a society together.