Still haven’t had COVID? Here’s why I’m still being cautious, how I’m assessing COVID safety, and how I’m dealing with feeling crazy.

Michael CalozBlog: Synthesizing & Simplifying Complexity, Living with the Pandemic2 Comments

dandelion blowing in the wind

Disclaimer: As always, I’m not a medical professional. I just read a lot of different articles and synthesize the information as best I can from the most reputable sources.

This post is written specifically with two types of people in mind, neither of whom have had COVID. Do you identify with one of these?

  1. You were much more careful in the past, but lately you’ve been easing up a bit. After all, we have to live our lives, right? What if things never really change?
  2. Even with mask mandates lifting, you’ve remained vigilant. Your friends think of you as “the careful one,” and you feel a bit crazy sometimes. It might feel like you’re the only one worrying so much. You’re confused about when it will make sense for you to stop being so cautious.

If you’ve already had COVID, you might still find this post useful, but you might also find it scary. I’m putting this warning up front because I want to be empathetic. In this post, I’m going to be making the case that caution is still warranted; but, it’s also worth mentioning that COVID treatments keep improving, and it might turn out that Long COVID isn’t as bad as it seems. Let’s hope so!

Here’s what I’m going to cover today:

  1. Why, despite things being so much better lately, I still think caution is very much still warranted in certain situations (e.g., recent studies show that 10-30% of people who got earlier COVID  variants experienced Long COVID, which can physically shrink the brain, causing changes equivalent to a decade of aging; and, we don’t yet know if or how that’s changed with Omicron);
  2. The most logical way I’ve seen of deciding what’s safe and what’s not;
  3. Why it’s so critical to get the booster;
  4. Why I think COVID safety is relevant to you if you’re into social justice or you’re a health-conscious person in general (e.g., you’re into exercising and taking supplements)
  5. Some tips to deal with the social anxiety of returning to socializing. 

Let’s get started.

In many ways, we’re all safer now than we were a few months ago. And, there’s still danger.

It’s wonderful that the death rate has been declining since February, and I’ve been happy to attend more social gatherings in person. 

But even if Omicron is less deadly than past variants, we’re now facing something potentially more dangerous: apathy.

You probably have friends who have completely stopped worrying about COVID. I don’t fully blame them, either. It’s been a very long 2.5 years, and the CDC has been terrible at communication.

It makes sense that we all want to forget about the pandemic and move on. (Plus, the forces of capitalism—via many governments and companies—want us to fully get back to work.)

I think that mentality is dangerous.

According to the World Health Organization on April 14, “COVID-19 is far from becoming an endemic disease and could still trigger large outbreaks around the globe.

The last thing I want to do is scare you or cause anxiety. We’ve all had enough of that.

But I think it’s important that you be aware of some of the startling research I’ve seen lately. Then, I’ll give you some simple tips to make decisions about what’s safe.

The effects of COVID are probably much more serious than you’ve imagined—yes, potentially even from “mild cases” of Omicron.

Here are some facts:

First, Long COVID is more dangerous and common than you might think.

From the American Medical Association on March 11: “It is estimated that anywhere from 10% to 30% of patients might experience long COVID after recovering—even if they weren’t very sick in the first place.

Some people have battled Long COVID for over two years now. We don’t know what exactly causes it (probably something related to the body’s inflammatory reaction), and we don’t know how to cure it. It can have devastating effects on your life.

From National Geographic in April reporting on a study in the journal Nature: “Brain scans now show that even a mild case of COVID-19 can shrink part of the brain, causing physical changes equivalent to a decade of aging… Exactly why is still a mystery… Of the roughly 80 million Americans who’ve gotten COVID-19 so far, about one of every four survivors suffers from impaired cognition, commonly described as brain fog… such as confusion, word-finding difficulties, short-term memory loss, dizziness, or inability to concentrate…”

But surely your chances of getting Long COVID are low with Omicron, and especially if you’ve been vaccinated… right?

Not so fast.

From March 24th in NPR: “Based on what’s known about the variant, no one really knows for sure whether people who get omicron could be more, or less, prone to getting long COVID. On the one hand, omicron is adept at evading the immune defenses put up by the vaccines, so it’s possible that ‘we might end up with more long COVID’… Alternatively, the variant leads to a more localized infection and doesn’t spread throughout the body as much, which means there could actually be fewer instances of long COVID.”

The effects of Long COVID could last years, or potentially for the rest of your life. We just don’t know enough yet.

(Similarly, we don’t know how reinfection—getting COVID after you’ve already had it before—affects your chances of getting Long COVID, or the severity of symptoms if you do. However, reinfections have “90% lower odds of resulting in hospitalization or death than primary infections.” So, that hopefully means that if you didn’t experience Long COVID symptoms after your first time, you might not after your second time either. But again, there hasn’t yet been a conclusive study on this.)

Second, researchers have been learning more about some additional effects of COVID.

On top of the typical Long COVID symptoms, there’s growing evidence that having had COVID increases your long-term risk of heart attack, stroke, accelerated aging, decreased brain volume, diabetes, and more:

  • From February 2022 in the journal Nature: “the risk and 1-year burden of cardiovascular disease in survivors of acute COVID-19 are substantial”;
  • From April 2022 in the journal Nature: COVID-19 can lead to “accelerated biological aging… [including] epigenetic aging and telomere attrition” (telomere length is typically associated with life expectancy);
    • (Here’s something worth remembering though about findings like this: The upside of the pandemic is that there’s been a huge amount of money put into studies like this that hadn’t been done before, so it might turn out that this kind of effect is actually more common from viral infections in general than we realized. In other words, it might not just be a COVID thing. Here’s a helpful Reddit thread discussing this.)
  • From March 2022 in the journal Nature: “There is strong evidence for brain-related abnormalities in COVID-19… Whether this deleterious impact can be partially reversed, or whether these effects will persist in the long term, remains to be investigated with additional follow up.”
  • From April 2022 in the British Medical Journal (as reported in The Guardian): “Catching Covid is associated with a fivefold increase in the risk of deep vein thrombosis (DVT) and a 33-fold increase in risk of a potentially fatal blood clot on the lung in the 30 days after becoming infected… Although the risks were highest in patients with more severe illness, even those with mild Covid had a threefold increased risk of DVT and a sevenfold increased risk of pulmonary embolism.
  • From March 2022 in The Lancet: “In the post-acute phase of the disease, compared with the contemporary control group, people with COVID-19 exhibited an increased risk… of incident diabetes.” Specifically, they found that people who had COVID-19 were about 40% more likely to develop diabetes within a year after recovering, compared to participants in a control group.
    • And, from NPR reporting on that study: “‘What’s surprising is that it is happening in people with no prior risk factors for diabetes” before becoming infected with COVID-19,’ said Ziyad Al-Aly, the lead author of the study.” He goes on to say that this means up to “1.6 million people [in the US alone] developing diabetes who might not have otherwise.”

According to Dr. Bob Wachter (Chairman of the UCSF Department of Medicine, one of the top hospitals in the US), there’s “substantial uncertainty” around the degree to which vaccination decreases any of these risks, whether the risks decrease with Omicron compared to previous variants, and whether or not antiviral medication makes a difference.

He adds: “The question: what am I willing to do to prevent symptomatic Covid? Am I willing to take a booster every 2-3 months? For me, probably yes, at least for a while – maybe until we have better boosters or a sure supply of Paxlovid or other effective antivirals along w/ evidence they reduce Long Covid risks. To those who say that a shot every few mths to prevent a bad disease is impossible, I’d ask them to talk to someone w/ Type 1 diabetes, who takes shots daily.” 

Awesome 😨. So what are we supposed to do about that? Wear masks forever?

Only indoors, and only during waves of infection. 

Yes, waves might keep popping up for many years. But no, that doesn’t mean we need to wear masks indoors every single day. It just means keeping an eye on the signals and staying extra safe by wearing a mask when things are particularly dangerous—just like deciding to put on sunscreen if you know you’ll be in the sun all day.

COVID might not ever go away completely, so I’m certainly not suggesting that you stay in high-alert mode for the rest of your life.

But, we understand the virus a lot better than we did a year ago, and dramatically better than we did two years ago.

In the future, we’ll know even more. The big questions for me at this point are (1) how much less likely is Long COVID from Omicron, and (2) how much less likely is Long COVID if you’ve been boosted (and how long does that protection last)?

If the answers turn out to be “a lot less likely,” then I’ll feel much better about not worrying about COVID (unless some hugely dangerous new variant appears). 

Also, children under 5 still can’t be vaccinated yet. So if you’re a parent (or spend time around people who are immunocompromised), it’s still especially important to be cautious until the vaccine is available to everyone and more treatment options are readily available (like Evushield for people who are immunocompromised).

All those facts about brain shrinkage and diabetes are scary, but it’s important to remember that most of those studies were conducted on the Alpha variant of COVID. We still don’t know how all that translates to Omicron. Let’s hope that Omicron does turn out to be as mild as everyone thinks it is. Until we know for sure though, I personally think caution makes sense.

Things are going to keep changing. How should we deal with that?

COVID is going to be with us for the foreseeable future. Just like with the flu, there are going to be quieter periods and “flare-up” periods.

So, I see three general options:

  1. Hyper-vigilant approach: You continue doom-scrolling every new COVID article you can find and never let yourself relax until COVID is completely gone (which might be never). 
  2. Head-in-sand approach: You decide that you’re completely done with worrying about COVID no matter how high cases rise or what new variants appear.
  3. Balanced approach: You check the numbers now and then and adjust your behavior accordingly. In other words, as I’ve been suggesting since the beginning of the pandemic: Follow the science.

You guessed it: The rest of this post is going to focus on approach #3. 

The best article I’ve seen recently on this approach is from March 30 on Vox.

As you might have heard, a lot of epidemiologists disagree with the CDC’s new laxer guidelines. One of them explains in that Vox article that the CDC’s guidelines are more about preventing system collapse (e.g., hospitals running out of beds again) rather than keeping individuals as safe as possible. 

So, based on that article and some others I’ve read, I’m going to give you some guidelines that are focused more on keeping yourself safe and healthy rather than just ensuring that our country is running smoothly.

(It’s worth naming too that this is coming from a place of privilege. Some people don’t have the ability to work from home, and some people are even forbidden from wearing a mask in their jobs. I feel a lot of empathy for you if you’re in that situation.)

Here’s the balanced approach I recommend for staying safe:

First, by far the most important thing is to get fully vaccinated (including the booster).

From a preprint study in January: “Vaccination… was associated with a substantial decrease in reporting the most common post-acute COVID-19 symptoms… in addition to reducing the risk of acute illness, COVID-19 vaccination may have a protective effect against long COVID.”

But, you should really get the booster too. From Harvard in January: “An additional ‘booster’ dose of Moderna or Pfizer mRNA-based vaccine is needed to provide immunity against the Omicron variant… We detected very little neutralization of the Omicron variant pseudovirus when we used samples taken from people who were recently vaccinated with two doses… But individuals who received three doses of mRNA vaccine had very significant neutralization against the Omicron variant.”

In other words, two vaccine doses alone don’t do much against Omicron. The booster is critical for protection.

Second, check the weekly case count like you check the weather.

Start here to check the local case rate. That link is to Multnomah County where I live in Portland, OR. But you can adjust it to your county and then bookmark that page. (Once you’ve bookmarked the page, it seems to first load the default page and then it takes around 10 seconds to automatically load the specific county you’ve bookmarked.)

(4/20 Update: I just noticed that the weekly “Case Rate per 100,000 population” number only updates once a week on Thursdays. But, once it fully loads, scroll down to right below the map below that and you’ll see a different number, “Case Rate (last 7 days),” which seems to be updated daily. I have no idea why they would show the less-frequently-updated number more prominently, but I wonder if it’s political pressure to downplay the severity, or possibly they apply some additional rigor to the calculation of the weekly number?)

If the “Case Rate (last 7 days)” number is…

  • Over 100: That indicates high transmission (i.e., wear a mask indoors). 
    • Private gatherings (like house parties) are high-risk events. Avoid crowded spaces (like airports) if you can. Wear an N95 or equivalent mask indoors (no indoor dining). (I’ve tried a lot of masks—here’s my favorite).
    • Even at this high level, the research I’ve found suggests that being maskless outdoors is fine for most people (unless you’re in a dense group of people, especially if they’re making noise, e.g., a mosh pit). So, all of these rules really only apply to being indoors with other people.
  • Between 50-100: That indicates substantial transmission (i.e., being unmasked indoors is ok if everyone is vaccinated).
    • Private gatherings (like house parties) are risky events. Wear an N95 or equivalent indoors unless over 75% of people around you are either masked or fully vaccinated (2 shots + booster). Indoor dining is ok if vaccination status is checked or you feel willing to take some risk (the risk here varies depending on how close the tables are together, how good the ventilation is, etc.).
  • Between 10-50: That indicates moderate transmission (i.e., being unmasked indoors is mostly ok).
    • If you don’t have any symptoms and you’re not immunocompromised or frequently in contact with people who are immunocompromised, being unmasked indoors should be ok unless it’s a highly-dense gathering and/or a lot of people are yelling, singing, etc. (e.g., an indoor concert).
    • (By the way, this level might seem relatively low now, but this was the level of transmission we were facing back when states first started issuing stay-at-home orders in March, 2020)
  • Less than 10: That indicates low transmission (i.e., most people don’t need to worry about COVID).
    • No special precautions are necessary unless you have symptoms or higher-risk people are nearby.

(As a reminder, even if the case count is above 100, the CDC’s website might still show “green/low” for your county. But again, according to virtually every epidemiologist I’ve read lately, that rating is more about politics or managing hospitals rather than prioritizing the health of the individual.)

The case count check is useful as a general gauge for “how cautious should I be right now?”

Of course, even if the case count is above 50 or 100, there’s a big difference between being maskless indoors with two friends versus thirty. To check how dangerous specific activities are, my favorite calculator is still Microcovid.

The above list of case count scenarios is also in line with a statistical analysis that was done to determine what it would take to “protect the most immune-compromised members of the community—people in whom vaccines provide zero protection against infection let alone severe disease” (which they defined as a less than 1% chance of becoming infected with COVID in a 4-month period for immune-compromised people in one-way masking situations; in other words, if they’re the only one wearing a mask).

What they found is that the weekly case rate per 100,000 would have to drop below 7.

By the way, those numbers I laid out in the bullets above are unfortunately still on the risky side because the case count numbers we can see online are most likely under-reporting.

Since so many people are using at-home testing kits now, it’s much harder to tell how many people are actually testing positive for COVID. Some cities are able to look at wastewater data, which tells a more complete story, but that’s not available everywhere.

For the foreseeable future, case counts are going to go through waves of rising and falling. 

To me, it becomes like checking the weather: every week, open up the tracker and see what the number is at. Just like how I’d choose to wear something different depending on if it’ll be hot & sunny or rainy, I might adjust my plans if the COVID case count number is higher or lower.

Special exceptions might make sense sometimes too.

When you’re considering whether or not to do an activity, another valuable question to ask yourself is, “How will I feel if I get COVID because of doing this?”

If you get COVID from eating dinner indoors at your best friend’s wedding, maybe it was worth it. If you get COVID from going maskless to the grocery store, maybe it wasn’t.

Ask yourself how rare or important an opportunity you’d be missing out on by choosing not to attend an event or choosing to wear a mask.

I also think it’s important to have an end in sight.

Ask yourself: In light of all the risks I’ve shared, what would it take for you to feel comfortable going to indoor, maskless social gatherings? 

Maybe it’s a low case count, or the vaccine being available to kids under 5, or a greater availability of treatments like Paxlovid or Evushield.

Although some version of COVID might be with us for many years, I’m personally waiting for one big thing to relax my caution: More conclusive studies on how prevalent Long COVID is with Omicron and what effect the booster has on Long COVID (i.e., how much additional protection it offers and how long it lasts).

And again, please do socialize outside!

All of the caution I’ve explained only applies to being maskless indoors (or to some kind of super-densely-packed, mosh pit type outdoor situation).

Social contact is important, so please feel free to be with friends outside and maskless.

(And, even indoor socializing can be safe if you follow the suggestions I’ve shared in the past. TL;DR: Risk is a function of environment, proximity, density, activity, others’ precautions, time, and protection. So, you reduce your risk by adjusting each of those. More info in the linked article.)

Let’s look at COVID safety as a combination of social justice and “health optimization.” 

How COVID safety relates to social justice:

Just like it’s easy for white people to go about our days not having to think about racism, it’s also easy for healthy people with highly-functioning immune systems to go through our days not having to think about people who are immunocompromised, don’t have great access to healthcare, or are otherwise marginalized in this way.

It’s worth pointing out that “immunocompromised” probably covers a much wider spectrum of people than you might be imagining. It’s not just people who were born with some rare disease. We’re talking about over 7 million Americans, including people who have received organ transplants, people who have diabetes, people on certain medications, and more.

So, if you’re someone who tries to be a strong ally when it comes to social justice issues like anti-racism and anti-sexism, this is another case where we can support others even if we’re doing fine ourselves. 

And yes, Omicron might be killing fewer people, but it’s still filling our hospitals more than at any other time in the pandemic. Here’s a quote from a physician via NPR: “Omicron is milder in the same way that a hurricane can be milder than a tornado: The tornado may cut a more destructive path with high-wind speeds, but the hurricane has a much bigger footprint.”

Even if you’re not hospitalized, you still might feel very miserable, even from Omicron. And if you’re someone who has the privilege of working from home and taking sick days, please think about other people you might transmit the virus to who don’t have those luxuries.

How COVID safety is a component of “health optimization”:

Are you a health-conscious person?

Some people don’t worry much about healthy eating, exercise, etc., and other people work hard to optimize their nutrition, prioritize sleep, buy organic food, take supplements, regularly go to the gym, etc.

No judgment here about which side of that spectrum you tend to fall on, but if you’re generally on the more health-conscious side, it seems to me like the negative effects of Long COVID would be dramatically worse than the positive effects you get by taking health supplements or optimizing your nutrition or workout routine.

Most Americans don’t exercise as much as doctors recommend. So, if you’re one of the smaller group that does prioritize health, it seems logical to me to also prioritize your COVID safety

Most people aren’t willing to put in all the work necessary to stay in great shape and eat well, so if you’re willing to do all that in exchange for health benefits, wouldn’t it also make sense to put in the work necessary to not get Long COVID, which might permanently damage your organs?

Yes, it’s annoying and uncomfortable to wear a mask, but so is lifting weights or going for a run.

I know that other people have different priorities too. Maybe you’re someone who more strongly prioritizes quality, in-person time with friends.

That’s valid—mental and emotional health are hugely important, and I won’t fault you for that.

For me though, although those things are important to me too, I’m willing to sacrifice a bit there in exchange for increased health. I see it as similar to my willingness to push myself to work out even when I really don’t feel like it.

I’m not aiming to moralize here, but to create a link between other common health practices and choosing to still wear a mask indoors if the conditions warrant it.

In other words, the only moralizing I’ll do is to say this: It seems strange to me to hear about other people like me (e.g., who put a lot of effort into their health) who have chosen to still not get boosted or who have completely stopped wearing masks. I’m hoping that this post might change your mind.

Do you feel crazy sometimes? Me too. And there’s nothing wrong with either of us.

If you’re still being cautious, it’s easy to feel gaslit—like you’re living in an alternate reality.

It might be small comfort to hear this, but I want to tell you: There’s nothing wrong with you. You’re not crazy.

This is a very dangerous disease, and it makes sense to want to stay safe, even if you see other people around you acting as if there’s nothing to worry about.

The truth is that our society has a short collective memory.

As you know if you follow the news in general, we’ll hear about some major scandal and everyone will be talking about it for a few weeks, then it’ll disappear as if it never happened. We’re already on to the next one.

It’s the same with the pandemic: Most people are happy as long as things feel safer now than they did a few months ago, even if the current case counts would have felt very scary a year ago.

And when it comes to the terrifying effects of Long COVID like brain shrinkage, I think the truth is that most people don’t even want to think about that—in the same way that we often filter out the truth about climate change from our conscious awareness.

To be fair, it’s not only that our society is forgetful.

There’s also the reality that we can’t stay afraid forever.

That’s not healthy, and it’s not practical. At some point, we need to get on with our lives. 

Yes, and, it doesn’t have to be all-or-nothing.

It doesn’t have to be just based on a gut feeling either.

It can be based on the clear metrics I outlined at the beginning: Is the new case count per 100K people above 100, above 50, above 10, or below 10?

In other words, the point at which we “get on with our lives” can be based on science and statistics.

A lot of us are experiencing social anxiety—we want to reconnect with friends, but it can be scary.

Even if the case count drops to the lowest level, you still might feel anxious about going to a social gathering. (I speak from experience!)

Here are some tips:

  1. You’re not broken. Remember that it’s 100% normal to be experiencing anxiety. Anxiety is a threat response, and COVID has been a very real threat. Your body is doing exactly what it’s supposed to be doing by warning you about perceived danger. There’s nothing wrong with you.
  2. Start small. If leaving the house is difficult, just do something easier like going for a walk in your neighborhood. Maybe invite one friend to walk with you, and wear masks if that makes you feel comfortable.
  3. Identify your triggers. If you want to go to a social gathering but you’re feeling nervous, spend some time slowing down and focusing on your breath and your body. Then, think about what specific things are causing you anxiety. Could you gather more information by asking the host some questions or making some simple requests? Could you make an agreement with yourself? For example: that you’re allowed to leave if you feel uncomfortable; that you’re only going for a certain amount of time; or that you’ll meet a friend there.
  4. Similarly, try lowering your standards. Notice if you’re being a perfectionist in any way. It’s ok if you act a little socially awkward. It’s ok if you’re not the life of the party. It’s ok if you don’t have the most fun time ever. Allow it to just be “ok” and not “great.”
  5. Allow yourself to not have to go back to how things were—maybe ever. If you were the type of person who experienced a lot of FOMO or kept your calendar packed with social events, what if this is an opportunity to change that? What if it becomes totally ok to “miss out” on all sorts of events that are happening in your community? Many things in life are cyclical, with high periods and low periods. Maybe you were doing a lot a few years ago, and now it’s ok to do less. Can you redefine what “success” looks like for you or what a “good life” looks like? Maybe a good, successful life can involve a lot of relaxing at home, hanging out with your favorite friends one-on-one, or going to the occasional larger social event, but only staying there for a little while and allowing yourself to leave while you’re still having fun.

Thanks for reading all that—I know it was a lot to take in.

We’re all figuring this out together, one step at a time.

I hope you have a nourishing day.

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