Normalize Covid

And Covidize Everything Else

Maybe being a busy primary care doctor means I have a skewed sample, but from my perspective, everyone has Covid.

Stuffy nose? Let’s check… positive. Sore throat? Let’s check… positive. Allergies? Let’s check… positive. Achy and tired? Let’s check… positive. Negative at home? Well, you never know, let’s check anyway… positive. Negative here three days ago and still not feeling better and now your husband and kids are sick? Let’s just check again… positive (this strain does seem to be false negative on rapid tests in the first few days, even in symptomatic patients, weirdly).

Meanwhile, no one is wearing a mask, and no one is testing who doesn’t want to know – which is a lot of people.

Can’t afford to miss work? “That’s OK, Doc, I’ll pass on the test. Just give me a little something to make it through the day.”

Have an excellent paid sick leave policy? “Absolutely, Doc, go right ahead and test, that’s why I’m here – gotta be responsible – by the way, it’s still 10 days of quarantine, right?”

Well no, actually, it hasn’t been 10 days of quarantine for a while, but you’re right, as far as the CDC is concerned, nothing has changed. If you test positive for Covid, the recommendation remains 5 full days of quarantine, followed by another five days of wearing a mask.

Now, mind you, Covid is not the only bug out there.

Every week an epidemiological report of syndromic trends data hits my inbox. For the week of September 9th, there were two dominant players with high activity: Human Rhinovirus/enterovirus, i.e. the common cold; and SARS-COV2, i.e. Covid. All the others – Flu, RSV, Adenovirus, etc. – were distant laggards.

Is it possible to tell the difference between Covid and the others without a test?

To be honest, it’s tough. Take Rhinovirus. Both present with cough, congestion, and sore throat. Covid seems to make you sicker for the first couple of days, with flu-like symptoms like fever, chills, and soreness, but not always. They both seem to be equally contagious, respond – or not – to all the usual OTC remedies, and last equally long (as the old adage goes: treat a cold, it’ll take a week; don’t treat a cold, it’ll take seven days).

As for Covid complications, they remain conspicuously scarce. Consider hospitalizations. Overall they are trending up, as they usually do this time of year. And many of those patients have Covid, as they would during any surge regardless of whether it’s the reason for admission.

A more meaningful statistic is Covid patients in the ICU, which would be rising fast if Covid were a significant cause of morbidity and mortality. That number has been low – essentially flat since Memorial Day.

Which begs the question: if there’s no longer much clinical difference between Covid and Cold/Flu, why should it still matter? Why do we persist in targeting Covid, but not Rhinovirus? It all feels a little schizoid. Prejudiced even! What did Covid ever do to you? OK, I know, a lot. But still… does any rationale remain for discriminating between viruses?

Well, for one thing, there are specific treatments for Covid, such as Paxlovid.

Granted, Paxlovid is not for everyone – the benefit is marginal, the side effects can be limiting, and there’s Paxlovid rebound, whereby the viral load surges when you stop the medication. However, it is recommended in certain patient populations, such as the elderly and immunocompromised. And you can’t use it if you don’t test for Covid.

For another thing, there’s the new Covid vaccine.

Would I recommend it? Yes, I would. Unless you’ve had Covid in the last three months, in which case it offers little additional protection. That’s another reason to test for Covid. Testing makes sense when the result would change the management, including whether to give the vaccine.

For a third thing, what about Long Covid?

I phrase that as a question because we still don’t know much about Long Covid, including whether or not repeat infections increase the risk. We do know that a small minority of patients can suffer serious complications and long-term sequelae from any viral infection, having to do with the immense complexity of the immune system.

We also know that the sicker you are and the sicker you get both increase the risk of Long Covid. Reassuringly – and this corresponds with my clinical experience – Long Covid appears to wane over time. Beyond all that, Long Covid largely remains a black box.

Back to our original question: Is it time to normalize Covid, or should we continue to set it apart? It seems that one can make an argument for both sides.

There’s a great Aramaic expression in the Talmud: Ma Nafshach. Literally, “What is your desire to say?” – a rhetorical question that means it doesn’t matter which side of the debate you are on: either way, the conclusion is the same.

Whether you see Covid as a virus apart or whether you see it as just another Cold/Flu makes no difference. Either way, the goal is the same: to reduce the spread of disease. Either way, the strategy should be the same: a uniform and practical policy of masking and vaccination for all viral respiratory illnesses.

Uniform, because we want to keep everyone healthy. Just because a particular pathogen like RSV may be a minor nuisance to you, doesn’t mean it’s not a threat to the more vulnerable.

Practical because of the law of unintended consequences. We have never done a great job at limiting the spread of Colds/Flu. Covid was the one exception, thanks to all its special rules and restrictions.

But now that Covid has become less deadly, maintaining these rules and restrictions only disincentivizes the 97% of the population over age 16 that has some level of immunity from even testing for Covid – including those who would at least wear a mask if they knew they had it.

With this “uniform and practical” standard in mind, here’s what I would recommend:

No more special Covid rules or restrictions: eliminate quarantine.

Be a mensch: if you are sick, wear a mask around others.

Don’t be a shmuck: if you are very sick, stay home.

Don’t be a putz: If you want to stay healthy, carry a mask for high-risk environments like planes, trains, buses and crowds.

Get vaccinated.

Have questions about whether it makes sense to test, treat, or vaccinate in your specific case? Ask your doctor – that’s what we are here for.

By normalizing Covid with less quarantine and isolation we can counterintuitively decrease its spread.

By Covidizing everything else with more masking and vaccination we can counter circulating pathogens – not to mention ones in the pipeline.

And those are very real.

As Simon Schama reminds us in his new book, Foreign Bodies; Pandemics, Vaccines, and the Health of Nations (look out for my review in the October issue of Commentary magazine and in next week’s Blog), Covid wasn’t the first deadly pandemic and it definitely will not be the last.

It’s time to put Covid in the rear-view mirror and shift our focus to health threats on the horizon. I hate to end on an alarmist note, but as my friend, the writer Zeynop Tufekci, warns in a well-researched and disturbingly convincing article in The New York Times, the storm clouds of Bird Flu are gathering….

Dr. Bertie Bregman
Dr. Bertie Bregman
Full Stack Family Medicine is a newsletter about what it’s really like to practice medicine and run a medical practice in New York City.
This blog will be a mix of stories, advice and discussion – topics will diverge widely, but they will all share a point of view!