Opinion | The Truth About Long Covid Is Complicated. Better Treatment Isn’t.

Opinion | The Truth About Long Covid Is Complicated. Better Treatment Isn’t.

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The Delta wave has intensified the Covid-19 pandemic in the United States just as children were preparing to return to school and adults were hoping for something like a return to their normal lives. Along with fears about rising hospitalizations and deaths, there are growing worries about another potential outcome of infection: long Covid for children and vaccinated adults who get mild breakthrough infections.

Reports of long Covid are everywhere, and they are alarming. However, understanding what the evidence really shows about the relationship between the Covid virus, SARS-CoV-2, and this syndrome may alleviate some fears.

Moreover, what could matter more than the cause of these long Covid symptoms is determining how to properly care for those who suffer from them. A thoughtful approach to this problem could also help us improve care more generally after the pandemic.

Long Covid has come to mean different things in different contexts and to different people.

Often, in academic studies, long Covid refers to cases in which people report one or more symptoms — like fatigue, coughing or loss of sense of smell — longer than what one might expect after the onset of illness. Given what we know about other respiratory infections, there should be little surprise that such symptoms sometimes persist. Ninety days after diagnosis of typical pneumonia, for instance, 51 percent of those affected still report fatigue, 32 percent coughing and 8 percent chest pain. Even a common cold can result in a prolonged cough. Typical upper respiratory tract infections can be associated with protracted loss of smell. Illness affects different people differently, and there is no hard rule for when particular symptoms should resolve.

However, long Covid is also sometimes used to describe lasting damage from the more severe respiratory syndromes that Covid is more likely than other respiratory diseases to cause and that make it so deadly. The most severe malady is acute respiratory distress syndrome, or ARDS, which involves profound, often deadly lung inflammation, typically treated with artificial ventilation in an intensive care unit. ARDS can cause a multitude of protracted health complications, whether caused by SARS-CoV-2 or something else.

Because Covid vaccines approved for emergency use in the United States are highly effective at preventing these most severe manifestations, we can safely assume they can prevent the effects of long Covid that stem from critical illness, like lung damage, kidney damage and delirium. Since children are at much lower risk of severe Covid, they should also be at relatively low risk for these serious consequences.

Yet when the term “long Covid” is used by the public, it can mean something quite different from damage inflicted by critical illness or the persistence of Covid symptoms.

Most people are instead referring to a chronic illness following a mild infection with a complex of multiple symptoms, including brain fog, severe fatigue, chronic pain, shortness of breath, palpitations, gastrointestinal symptoms and much more. But the link between SARS-CoV-2 and this syndrome is complicated and not entirely clear.

One peer-reviewed study of people who reported long Covid symptoms noted that most of those who were tested for antibodies that provide evidence of a previous SARS-CoV-2 infection had negative results. The level of symptoms, moreover, was virtually the same whether the person was positive or negative for antibodies. A second study, not peer reviewed, of adults referred for long Covid management similarly reported that no Covid antibodies were found in 61 percent of them, again without differences in symptoms whether testing was positive or negative.

Antibody testing has some level of false negatives, and antibody levels can wane; however, most people with a prior infection have antibodies for some time, so such testing remains informative overall.

Another non-peer-reviewed study found that the rates of adolescents reporting symptoms such as fatigue and memory loss that are often attributed to long Covid were the same among those who had a mild SARS-CoV-2 infection and those who had not been infected, as ascertained by antibody testing.

This suggests that the syndrome may have multiple causes, even within a single person. Psychosocial strain could be one contributing factor, particularly in light of the sharp increase in psychological distress amid the tragedy of the pandemic.

Yet in many ways, the precise cause of these symptoms doesn’t matter. We need to make our schools and workplaces safe and to take other public health measures to contain viral spread and buy time to vaccinate the population. That is true regardless of the nature of the connection between SARS-CoV-2 and this form of long Covid.

The causes of these illnesses do matter when it comes to treatment. For instance, if we understand this form of long Covid as a complex chronic illness, a biopharmaceutical solution is unlikely, and there may be no single cure. Rather, over time, a compassionate, humanistic team of professionals from multiple disciplines, including rehabilitation, can validate patients’ experiences and collaborate with them to improve their health in incremental yet significant ways.

No matter what the underlying cause and whether there is evidence of prior infection, long Covid, even among those with little or no evidence of previous infection, brings significant suffering, including several reported deaths by suicide. Action and not just acknowledgment is needed.

We must move beyond a false mind-body dichotomy that stigmatizes physical symptoms that are bound up with mental suffering. We need more support for the vulnerable and those lacking basic needs, so often those most harmed by chronic illness. This makes the need for universal health care even more urgent to ensure care for all with equal consideration of mental health.

Addressing the Covid-19 pandemic and long Covid itself requires not just containing the outbreak but also providing adequate social supports and medical care for all. The Covid-19 pandemic cannot be undone, but we can take steps to mitigate its impact — and to make our health care system a better one in its wake.


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