The new rules for feeling sick

The maskless man a few rows back coughed his head off. I’d just boarded the train from DC to New York City a few weeks ago and, along with several other passengers, were racking my neck to see what was going on. This was not the cane of a lingering cold. This was a deep, constant, strong cough. Think of waste processing with a fork in it.

No one said anything to the man (at least as far as I know). But if someone had, I imagine they would have responded with a now familiar pandemic-era chorus: “Don’t worry! It’s not Covid!” Such assurances can be fine (polite, even), say, at the height of allergy season, when you want a concerned-looking company to know that you’re not, in fact, flooding them with deadly virus. But guarantees only go so far. As my colleague Katherine J. Wu recently wrote, a negative COVID test, especially in the early days of symptomatic illness, is no guarantee that you are not infected and contagious. And put aside even that worry, still: Whatever it was that left that maskless man hacked away like a broken kitchen appliance, I didn’t want that either!

If you’re feeling sick just because you don’t have COVID, “it doesn’t mean you take off your mask and get on a plane next to other people — that’s rude,” Emily Landon, an infectious disease physician at the University of Chicago, told me. “Maybe you’re ruining someone’s vacation…Maybe they’ll see their mom in hospice. Let’s not ruin other people’s lives and plans.”

In the past two years, the public has taken a crash course in preventing the transmission of respiratory viruses. We learned the importance of testing and masking and distancing and insulating and ventilating. These lessons, some better received than others, apply just as much to better-known pathogens like the flu and cold coronaviruses as they do to the new ones that have reshaped our lives. We understand better than ever how to be a good sick person. Now we’ll see if anyone applies that knowledge.

The first and most important rule for feeling sick is to stay at home. This, says Ryan Langlois, an immunologist at the University of Minnesota, is “the easiest and the most difficult” guideline at the same time. Easy because it’s that simple: Stay in your house! Do not go away! No technical expertise required. Difficult because actually following them entails major disruptions to daily life. For white-collar workers, the normalization of homeworking has made this a lot more convenient than it was (and one can only hope, dispel once and for all the fiction that dragging yourself sick to work is an act of your own – sacrificing fortitude; that is it doesn’t – it’s just inconsiderate). However, for much of the workforce, remote working is not an option, and more than a fifth of American workers do not have paid sick leave. Of the country’s lowest earners – the people who need it most – only about a third are to do† (Every wealthy country in the world except the United States guarantees paid sick leave.)

The complicated part of isolating is knowing when to stop. No single formula will give the right answer in all cases, for every type of infection, Langlois told me. One person can be completely virus-free five days after the onset of symptoms; another can still be highly contagious. Even for the most responsible among us, this ambiguity can lead to tricky calculations. Can you afford to miss that work meeting? How about a family dinner? It would be really annoying to cancel those travel plans, but should you?

After a few years of COVID management, at least in theory we have better tools and practices to help people manage these situations. Many of us have gotten into the habit of regularly testing and retesting ourselves for COVID, and now is not the time to stop. But Seema Lakdawala, a flu transmission expert at the University of Pittsburgh, envisions a world with universally accessible tests for a slew of pathogens: flu, RSV, adenovirus, rhinovirus, seasonal cold-causing coronaviruses and, of course, SARS-CoV-2. Locations on every street corner would provide patients with not only a diagnosis, but also a prescription for the right medication. Rural people could buy home tests from drug stores or order them online. Someone who only tested positive for a seasonal coronavirus could undergo more relaxed isolation (for example, Langlois doesn’t think it’s practical to ask people to stay home completely for a cold, although they certainly still need to mask), while someone who tested positive for flu, which kills tens of thousands of people most years, would know they need to take stricter precautions. Whatever the situation, you would know you were free when you tested negative for what you originally tested positive for.

For now, Lakdawala admits that a world of such universal, accessible tests remains a distant fantasy. She and the other experts I spoke to offered some more practical tips. Even when the going gets tough, it’s good practice to notify people who may have been exposed to a pathogen, just as we’ve been encouraged to do with COVID. If you have a fever, keep as much to yourself as possible for at least 24 hours after it has gone down. If you don’t have a fever, Landon told me, you should be free to rejoin society after your symptoms have subsided. For a common cold, she said, it generally takes three to five days; for the flu, five to seven. Certain symptoms can persist for weeks afterward, but as long as you don’t feel disgusted, Landon said, you can responsibly go outside. (Call it the “ew” test.) Leaving isolation with a persistent cough is fine, Saskia Popescu, an epidemiologist at George Mason University, told me, “as long as it’s not that wet, nasty cough.” (If you’re really interested in getting to the bottom of the matter, you can always check the CDC’s 206-page doorstop on insulation measures, but Popescu doesn’t recommend, “I wouldn’t subject anyone to that.”)

If you still have symptoms after the recommended isolation period, or if you need to get out before it’s over, whether it’s for an essential message or because your employer won’t grant sick leave, you should wear a high-quality mask. The same is true, Landon told me, about that ambiguous period when you feel a little nauseous and just start to wonder if you’re running into something: if you’re not sure, mask up. People are usually quite contagious at that stage, and the worst that can happen is you take a little unnecessary precaution and wake up feeling great the next morning. Yes, masks can be uncomfortable, and yes, it’s a tragedy that such a fundamental health intervention has been included in the culture war, but they remain one of the most effective, least disruptive tools we have at our disposal to fight all types of respiratory tract. . infections. An N95 or KN95 is best, but a surgical or cloth mask is better than nothing, Lakdawala said, especially since many people can’t afford to constantly replenish stocks of premium disposables. Healthcare providers and employers, she suggested, could offer free masks, which would protect patients, employees and those around them.

Like widespread testing, a continuous supply of free masks and universal paid sick leave are just a distant vision. Congress is currently struggling to support our most basic public health infrastructure during a pandemic, forcing Americans to sort out COVID themselves. The same will probably be true for all the other known viruses with which we are re-acquainted with ourselves. Whether the more modest behavioral changes we’ve made over the past two years will last longer than the pandemic is a mystery. In this age of constant flux, a constant has been the discrepancy between what we know we should be doing and what we are ultimately going to do.

Better to know than not, but personal experience has not made me optimistic that knowledge will be reliably translated into action. On the train, after waiting fruitlessly for a few minutes to see if the man would stop coughing a few rows back, I packed my bags and got into another car. At first everything was quiet. Then two people started coughing.