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Tag: good health

  • This Fall’s COVID Vaccines Are for Everyone

    This Fall’s COVID Vaccines Are for Everyone

    Paul Offit is not an anti-vaxxer. His résumé alone would tell you that: A pediatrician at Children’s Hospital of Philadelphia, he is the co-inventor of a rotavirus vaccine for infants that has been credited with saving “hundreds of lives every day”; he is the author of roughly a dozen books on immunization that repeatedly debunk anti-vaccine claims. And from the earliest days of COVID-19 vaccines, he’s stressed the importance of getting the shots. At least, up to a certain point.

    Like most of his public-health colleagues, Offit strongly advocates annual COVID shots for those at highest risk. But regularly reimmunizing young and healthy Americans is a waste of resources, he told me, and invites unnecessary exposure to the shots’ rare but nontrivial side effects. If they’ve already received two or three doses of a COVID vaccine, as is the case for most, they can stop—and should be told as much.

    His view cuts directly against the CDC’s new COVID-vaccine guidelines, announced Tuesday following an advisory committee’s 13–1 vote: Every American six months or older should get at least one dose of this autumn’s updated shot. For his less-than-full-throated support for annual vaccination, Offit has become a lightning rod. Peers in medicine and public health have called his opinions “preposterous.” He’s also been made into an unlikely star in anti-vaccine circles. Public figures with prominently shot-skeptical stances have approvingly parroted his quotes. Right-leaning news outlets that have featured vaccine misinformation have called him up for quotes and sound bites—a sign, he told me, that as a public-health expert “you screwed up somehow.”

    Offit stands by his opinion, the core of which is certainly scientifically sound: Some sectors of the population are at much higher risk for COVID than the rest of us. But the crux of the controversy around his view is not about facts alone. At this point in the pandemic, in a country where seasonal vaccine uptake is worryingly low and direly inequitable, where health care is privatized and piecemeal, where anti-vaccine activists will pull at any single loose thread, many experts now argue that policies riddled with ifs, ands, or buts—factually sound though they may be—are not the path toward maximizing uptake. “The nuanced, totally correct way can also be the garbled-message way,” Anthony Fauci, the former director of the National Institute of Allergy and Infectious Diseases, told me.

    For the past two years, the United States’ biggest COVID-vaccine problem hasn’t been that too many young and healthy people are clamoring for shots and crowding out more vulnerable groups. It’s been that no one, really—including those who most need additional doses—is opting for additional injections at all. America’s vaccination pipeline is already so riddled with obstacles that plenty of public-health experts have become deeply hesitant to add more. They’re opting instead for a simple, proactive message—one that is broadly inclusive—in the hope that a concerted push for all will nudge at least some fraction of the public to actually get a shot this year.

    On several key vaccination points, experts do largely agree. The people who bear a disproportionate share of COVID’s risk should receive a disproportionate share of immunization outreach, says Saad Omer, the dean of UT Southwestern’s O’Donnell School of Public Health.

    Choosing which groups to prioritize, however, is tricky. Offit told me he sees four groups as being at highest risk: people who are pregnant, immunocompromised, over the age of 70, or dealing with multiple chronic health conditions. Céline Gounder, an infectious-disease specialist and epidemiologist at NYC Health + Hospitals/Bellevue, who mostly aligns with Offit’s stance, would add other groups based on exposure risk: people living in shelters, jails, or other group settings, for instance, and potentially people who work in health care. (Both Gounder and Offit also emphasize that unvaccinated people, especially infants, should get their shots this year, period.) But there are other vulnerable groups to consider. Risk of severe COVID still stratifies by factors such as socioeconomic status and race, concentrating among groups who are already disproportionately disconnected from health care.

    That’s a potentially lengthy list—and messy messaging has hampered pandemic responses before. As Gretchen Chapman, a vaccine-behavior expert at Carnegie Mellon University, told me last month, a key part of improving uptake is “making it easy, making it convenient, making it the automatic thing.” Fauci agrees. Offit, had he been at the CDC’s helm, would have strongly recommended the vaccine for only his four high-risk groups, and merely allowed everyone else to get it if they wanted to—drawing a stark line between those who should and those who may. Fauci, meanwhile, approves of the CDC’s decision. If it were entirely up to him, “I would recommend it for everyone” for the sheer sake of clarity, he told me.

    Read: Fall’s vaccine routine didn’t have to be this hard

    The benefit-risk ratio for the young and healthy, Fauci told me, is lower than it is for older or sicker people, but “it’s not zero.” Anyone can end up developing a severe case of COVID. That means that shoring up immunity, especially with a shot that targets a recent coronavirus variant, will still bolster protection against the worst outcomes. Secondarily, the doses will lower the likelihood of infection and transmission for at least several weeks. Amid the current rise in cases, that protection could soften short-term symptoms and reduce people’s chances of developing long COVID; it could minimize absences from workplaces and classrooms; it could curb spread within highly immunized communities. For Fauci, those perks are all enough to tip the scales.

    Offit did tell me that he’s frustrated at the way his views have frequently been framed. Some people, for instance, are inaccurately portraying him as actively dissuading people from signing up for shots. “I’m not opposed to offering the vaccine for anyone who wants it,” he told me. In the case of the young and healthy, “I just don’t think they need another dose.” He often uses himself as an example: At 72 years old, Offit didn’t get the bivalent shot last fall, because he says he’s in good health; he also won’t be getting this year’s XBB.1-targeting brew. Three original-recipe shots, plus a bout of COVID, are protection enough for him. He gave similar advice to his two adult children, he told me, and he’d say the same to a healthy thrice-dosed teen: More vaccine is “low risk, low reward.”

    The vax-for-all guideline isn’t incompatible, exactly, with a more targeted approach. Even with a universal recommendation in place, government resources could be funneled toward promoting higher uptake among essential-to-protect groups. But in a country where people, especially adults, are already disinclined to vaccinate, other experts argue that the slight difference between these two tactics could compound into a chasm between public-health outcomes. A strong recommendation for all, followed by targeted implementation, they argue, is more likely to result in higher vaccination rates all around, including in more vulnerable populations. Narrow recommendations, meanwhile, could inadvertently exclude people who really need the shot, while inviting scrutiny over a vaccine’s downsides—cratering uptake in high- and low-risk groups alike. Among Americans, avoiding a strong recommendation for certain populations could be functionally synonymous with explicitly discouraging those people from getting a shot at all.

    Offit pointed out to me that several other countries, including the United Kingdom, have issued recommendations that target COVID vaccines to high-risk groups, as he’d hoped the U.S. would. “What I’ve said is really nothing that other countries haven’t said,” Offit told me. But the situation in the U.S. is arguably different. Our health care is privatized and far more difficult to access and navigate. People who are unable to, or decide not to, access a shot have a weaker, more porous safety net—especially if they lack insurance. (Plus, in the U.K., cost was reportedly a major policy impetus.) A broad recommendation cuts against these forces, especially because it makes it harder for insurance companies to deny coverage.

    Read: The big COVID question for hospitals this fall

    A weaker call for COVID shots would also make that recommendation incongruous with the CDC’s message on flu shots—another universal call for all Americans six months and older to dose up each year. Offit actually does endorse annual shots for the flu: Immunity to flu viruses erodes faster, he argues, and flu vaccines are “safer” than COVID ones.

    It’s true that COVID and the flu aren’t identical—not least because SARS-CoV-2 continues to kill and chronically sicken more people each year. But other experts noted that the cadence of vaccination isn’t just about immunity. Recent studies suggest that, at least for now, the coronavirus is shape-shifting far faster than seasonal flu viruses are—a point in favor of immunizing more regularly, says Vijay Dhanasekaran, a viral-evolution researcher at the University of Hong Kong. The coronavirus is also, for now, simply around for more of the year, which makes infections more likely and frequent—and regular vaccination perhaps more prudent. Besides, scientifically and logistically, “flu is the closest template we have,” Ali Ellebedy, an immunologist at Washington University in St. Louis, told me. Syncing the two shots’ schedules could have its own rewards: The regularity and predictability of flu vaccination, which is typically higher among the elderly, could buoy uptake of COVID shots—especially if manufacturers are able to bundle the immunizations into the same syringe.

    Flu’s touchstone may be especially important this fall. With the newly updated shots arriving late in the season, and COVID deaths still at a relative low, experts are predicting that uptake may be worse than it was last year, when less than 20 percent of people opted in to the bivalent dose. A recommendation from the CDC “is just the beginning” of reversing that trend, Omer, of UT Southwestern, told me. Getting the shots also needs to be straightforward and routine. That could mean actively promoting them in health-care settings, making it easier for providers to check if their patients are up to date, guaranteeing availability for the uninsured, and conducting outreach to the broader community—especially to vulnerable groups.

    Offit hasn’t changed his mind on who most needs these new COVID vaccines. But he is rethinking how he talks about it: “I will stop putting myself in a position where I’m going to be misinterpreted,” he told me. After the past week, he more clearly sees the merits of focusing on who should be signing up rather than who doesn’t need another dose. Better to emphasize the importance of the shot for the people he worries most about and recommend it to them, without reservation, to whatever extent we can.

    Katherine J. Wu

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  • Americans Eat Obscene Amounts of Protein. Is It Enough?

    Americans Eat Obscene Amounts of Protein. Is It Enough?

    For years, the American approach to protein has been a never-ending quest for more. On average, each person in the United States puts away roughly 300 pounds of meat a year; we are responsible for more than a third of the multibillion-dollar protein-supplement market. Our recommended dietary allowance, or RDA, for protein is 0.8 grams per kilogram of body weight per day—a quota that a 160-pound person could meet with a couple of eggs in the morning and an eight-ounce steak at night. American adults consistently eat well above that amount, with men close to doubling it—and recent polls show that millions of us want to increase our intake.

    The American appetite for protein is, simply put, huge. And still, Jose Antonio thinks we’re getting nowhere near enough.

    The RDA of 0.8 grams per kilogram is “nothing, literally nothing,” Antonio, a health-and-human-performance researcher at Nova Southeastern University, in Florida, told me. “Most of my friends get that at breakfast.” In an ideal world, Antonio said, totally sedentary adults should consume at least twice that; people who seriously exercise should start with a minimum of 2.2 grams per kilogram, and ramp their levels up from there. (Antonio is also a co-founder of the International Society of Sports Nutrition, which has received sponsorships from companies that sell protein supplements.)

    In Antonio’s pro-protein world, people would be fitter, more energetic, and suffer less chronic disease; they’d build muscle more efficiently, and recover faster from workouts. There is no definitive cap, in his view, on how much protein people should strive for. The limit, he said, is “How much can a human consume in a single day?”

    Among nutritionists, Antonio’s viewpoint is pretty fringe. There is, other experts told me, such a thing as too much protein—or at least a point of rapidly diminishing returns. But researchers don’t agree on how much protein is necessary, or how much is excessive; they’ve reached no consensus on the extent of its benefits, or whether eating extra servings can send our health into decline. Which leaves Americans with no protein ceiling—and plenty of room for our protein hunger to grow, and grow, and grow.

    Read: You’re probably drinking enough water

    Not having enough protein is clearly very bad. Protein is essential to the architecture of our cells; we rely on it for immunity and hormone synthesis, and cobble it together to build muscles, skin, and bone. Among the three macronutrients—the other two being carbohydrates and fat—protein is the only one that “we need to get every day,” Joanne Slavin, a nutrition researcher at the University of Minnesota, told me. Nearly half of the 20 amino-acid building blocks that make up protein can’t be produced in-house. Go without them for too long, and the body will start to break its own tissues down to scavenge the molecules it needs.

    That state of deficiency is exactly what the protein RDA was designed to avoid. Researchers decided the threshold decades ago, based on their best estimations of the amount of protein people needed to balance out their loss of nitrogen—a substance that’s in amino acids but that the body can’t itself make. The average person in the study, they found, needed 0.66 grams of protein per kilogram of body weight to avoid going into the red. So they set the guidelines at 0.8, a level that would keep the overwhelming majority of the population out of the deficiency zone. That number has stuck in the many years since, and Slavin, who has sat on the Dietary Guidelines Advisory Committee, sees no reason for it to change. People who are expending extra energy on growth, or whose muscles are taxed by exercise or aging, might need more. But for the typical American adult, Slavin said, “I think 0.8 is the right number.”

    Others vehemently disagree. The current standard is “not enough to support everyday living,” Abbie Smith-Ryan, a sports-nutrition expert at the University of North Carolina at Chapel Hill, told me. Adults, she and others told me, should be getting more like 1.2 or 1.6 grams per kilogram at baseline. Their beef with the RDA is twofold. For one, the original nitrogen analyses oversimplified how the body metabolizes and retains protein, Stuart Phillips, a protein researcher at McMaster University, in Canada, told me. And second, even if the 0.8 number does meet our barest needs, “there’s a much more optimal amount we should be consuming” that would further improve our health, Katie Hirsch, an exercise physiologist at the University of South Carolina, told me. (I reached out to the USDA, which helps develop the U.S.’s official Dietary Guidelines, about whether the RDA needed to change; a spokesperson referred me to the National Academy of Sciences, which said that the RDA was last reviewed in 2002, and was expected to be reviewed again soon.)

    If Hirsch and others are right, even people who are slightly exceeding the government guideline might not be maximizing their resilience against infections, cardiovascular disease, metabolic issues, muscle loss, and more. People who are working out and still eating the measly 0.8 grams per kilogram per day, Antonio told me, are also starving themselves of the chance to build lean muscle—and of performance gains.

    But the “more” mentality has a limit. Experts just can’t agree on what it is. It does depend on who’s asking, and their goals. For most people, the benefits “diminish greatly” past 1.6 grams per kilogram, Phillips told me. Smith-Ryan said that levels around 2.2 were valid for athletes trying to lose weight. Antonio is more liberal still. Intakes of 3.3 or so are fair game for body builders or elite cyclists, he told me. In one of his studies, he had athletes pack in 4.4 grams of protein per kilogram of body weight for weeks—a daily diet that, for a 160-pound person, would require three-plus pounds of steak, 16 cups of tofu, or 89 egg whites.

    Read: The Jordan Peterson all-meat diet

    That is … a lot of protein. And most of the other experts I spoke with said that they didn’t see the point, especially for Americans, who already eat more protein than people in most other countries. “There’s very little evidence that more is better,” Marion Nestle, a nutrition researcher at New York University, told me.

    The worry isn’t necessarily that tons of protein would cause acute bodily harm, at least not to people who are otherwise in good health. Over the years, researchers have raised concerns that too much protein could damage the kidneys or liver, leach calcium from the bones, or even trigger cancer or early death—but the evidence on all fronts is, at best, mixed. In Antonio’s high-protein studies with athletes, he told me, their organs have remained in tip-top shape. The known drawbacks are more annoying than dangerous: High-protein diets can raise the risk of bloating, gas, and dehydration; burning through tons of protein can also make people feel very, very hot. Roughly a quarter of the participants in Antonio’s ultra-high-protein study dropped out: Many of them felt too full, he told me, and no longer enjoyed food. One volunteer was so plagued by night sweats by the close of the trial, he said, that she could no longer fall asleep.

    Whether many years of an ultrahigh-protein lifestyle could be harmful is less clear. Native communities in the Arctic have healthfully subsisted on such diets for generations, but they’ve had a long time to adapt; those in Western society might not fare the same.

    Over the years, it’s gotten easy to interpret protein’s apparent lack of immediate downsides as permission to reach for more. But for now, many experts would rather err on the side of moderation. “Would I feed that much to one of my relatives? I would not,” Susan Roberts, a nutrition researcher at Tufts University, told me. Even if protein itself turns out not to be hard on the body, the foods it comes in still might be, including processed meats or sugary “high-protein” powders, shakes, cookies, chips, and bars. People pounding protein also risk squeezing other nutrients out of their diet, Roberts told me—whole grains, nuts, fruits, and vegetables, all of them packed with fiber, a vital ingredient that nutritionists actually do agree we lack.

    Read: Selling the fantasy of high-protein everything

    Plus, Slavin argued, there’s a point at which excess protein becomes a straight-up waste. When people eat more than about 20 to 40 grams of protein in a single sitting, their protein-processing machinery can get overwhelmed; the body eliminates the nitrogen as waste, then treats the rest as it would a carbohydrate or fat. “You can get fat on proteins just like you can get fat on carbohydrates,” Slavin told me. Which makes overdoing protein, in her eyes, “expensive and stupid.”

    The excess can have consequences beyond what our own bodies endure. Meat production drives greenhouse-gas emissions and uses up massive tracts of land. And Maya Almaraz, a food-systems researcher at Princeton, has found that the majority of the nitrogen pollution in wastewater is a by-product of our diets. The more protein we eat, the more we might be feeding toxic algal blooms.

    There’s no denying that protein deficiency is a problem in many parts of the world, even within the United States. Protein sources are expensive, putting them out of reach of poor communities. Meanwhile, many of the people who worry most about getting enough of it—the wealthy, the ultra-athletic, the educated—are among those who need to supplement the least. Experts, for now, may not agree on how much protein is too much for individuals. But if appetite is all we have to curb our intake, going all in on protein might create problems bigger than anything we’ve had to stomach so far.

    Katherine J. Wu

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  • The Future of Long COVID

    The Future of Long COVID

    In the early spring of 2020, the condition we now call long COVID didn’t have a name, much less a large community of patient advocates. For the most part, clinicians dismissed its symptoms, and researchers focused on SARS-CoV-2 infections’ short-term effects. Now, as the pandemic approaches the end of its third winter in the Northern Hemisphere, the chronic toll of the coronavirus is much more familiar. Long COVID has been acknowledged by prominent experts, national leaders, and the World Health Organization; the National Institutes of Health has set up a billion-dollar research program to understand how and in whom its symptoms unfurl. Hundreds of long-COVID clinics now freckle the American landscape, offering services in nearly every state; and recent data hint that well-vetted drugs to treat or prevent long COVID may someday be widespread. Long COVID and the people battling it are commanding more respect, says Hannah Davis, a co-founder of the Patient-Led Research Collaborative, who has had long COVID for nearly three years: Finally, many people “seem willing to understand.”

    But for all the ground that’s been gained, the road ahead is arduous. Long COVID still lacks a universal clinical definition and a standard diagnosis protocol; there’s no consensus on its prevalence, or even what symptoms fall under its purview. Although experts now agree that long COVID does not refer to a single illness, but rather is an umbrella term, like cancer, they disagree on the number of subtypes that fall within it and how, exactly, each might manifest. Some risk factors—among them, a COVID hospitalization, female sex, and certain preexisting medical conditions—have been identified, but researchers are still trying to identify others amid fluctuating population immunity and the endless slog of viral variants. And for people who have long COVID now, or might develop it soon, the interventions are still scant. To this day, “when someone asks me, ‘How can I not get long COVID?’ I can still only say, ‘Don’t get COVID,’” says David Putrino, a neuroscientist and physical therapist who leads a long-COVID rehabilitation clinic at Mount Sinai’s Icahn School of Medicine.

    As the world turns its gaze away from the coronavirus pandemic, with country after country declaring the virus “endemic” and allowing crisis-caliber interventions to lapse, long-COVID researchers, patients, and activists worry that even past progress could be undone. The momentum of the past three years now feels bittersweet, they told me, in that it represents what the community might lose. Experts can’t yet say whether the number of long-haulers will continue to increase, or offer a definitive prognosis for those who have been battling the condition for months or years. All that’s clear right now is that, despite America’s current stance on the coronavirus, long COVID is far from being beaten.

    Despite an influx of resources into long-COVID research in recent months, data on the condition’s current reach remain a mess—and scientists still can’t fully quantify its risks.

    Recent evidence from two long-term surveys have hinted that the pool of long-haulers might be shrinking, even as new infection rates remain sky-high: Earlier this month, the United Kingdom’s Office for National Statistics released data showing that 2 million people self-reported lingering symptoms at the very start of 2023, down from 2.3 million in August 2022. The U.S. CDC’s Household Pulse Survey, another study based on self-reporting, also recorded a small drop in long-COVID prevalence in the same time frame, from about 7.5 percent of all American adults to roughly 6. Against the massive number of infections that have continued to slam both countries in the pandemic’s third year and beyond, these surveys might seem to imply that long-haulers are leaving the pool faster than newcomers are arriving.

    Experts cautioned, however, that there are plenty of reasons to treat these patterns carefully—and to not assume that the trends will be sustained. It’s certainly better that these data aren’t showing a sustained, dramatic uptick in long-COVID cases. But that doesn’t mean the situation is improving. Throughout the pandemic, the size of the long-COVID pool has contracted or expanded for only two reasons: a change in the rate at which people enter, or at which they exit. Both figures are likely to be in constant flux, as surges of infections come and go, masking habits change, and vaccine and antiviral uptake fluctuates. Davis pointed out that the slight downward tick in both studies captured just a half-year stretch, so the downward slope could be one small portion of an undulating wave. A few hours spent at the beach while the tide is going out wouldn’t be enough to prove that the ocean is drying up.

    Read: We’re bungling the COVID wind-down

    Recent counts of new long-COVID cases might also be undercounts, as testing slows and people encounter more challenges getting diagnosed. That said, it’s still possible that, on a case-by-case basis, the likelihood of any individual developing long COVID after a SARS-CoV-2 infection may have fallen since the pandemic’s start, says Deepti Gurdasani, a clinical epidemiologist at Queen Mary University of London and the University of New South Wales. Population immunity—especially acquired via vaccination—has, over the past three years, better steeled people’s bodies against the virus, and strong evidence supports the notion that vaccines can moderately reduce the risk of developing long COVID. Treatments and behavioral interventions that have become more commonplace may have chipped away at incidence as well. Antivirals can now help to corral the virus early in infection; ventilation, distancing, and masks—when they’re used—can trim the amount of virus that infiltrates the body. And if overall exposure to the virus can influence the likelihood of developing long COVID, that could help explain why so many debilitating cases arose at the very start of the pandemic, when interventions were few and far between, says Steven Deeks, a physician researcher at UC San Francisco.

    There’s not much comfort to derive from those individual-level stats, though, when considering what’s happening on broader scales. Even if immunity makes the average infected person less likely to fall into the long-COVID pool, so many people have been catching the virus that the inbound rate still feels like a flood. “The level of infection in many countries has gone up substantially since 2021,” Gurdasani told me. The majority of long-COVID cases arise after mild infections, the sort for which our immune defenses fade most rapidly. Now that masking and physical distancing have fallen by the wayside, people may be getting exposed to higher viral doses than they were a year or two ago. In absolute terms, then, the number of people entering the long-COVID pool may not really be decreasing. Even if the pool were getting slightly smaller, its size would still be staggering, an ocean of patients with titanic needs. “Anecdotally, we still have an enormous waitlist to get into our clinic,” Putrino told me.

    Deeks told me that he’s seen another possible reason for optimism: People with newer cases of long COVID might be experiencing less debilitating or faster-improving disease, based on what he’s seen. “The worst cases we’ve seen come from the first wave in 2020,” he said. But Putrino isn’t so sure. “If you put an Omicron long-COVID patient in front of me, versus one from the first wave, I wouldn’t be able to tell you who was who,” he said. The two cases would also be difficult to compare, because they’re separated by so much time. Long COVID’s symptoms can wax, wane, and qualitatively change; a couple of years into the future, some long-haulers who’ve just developed the condition may be in a spot that’s similar to where many veterans with the condition are now.

    Read: The flu-ification of COVID policy is almost complete

    Experts’ understanding of how often people depart the long-COVID pool is also meager. Some long-haulers have undoubtedly seen improvement—but without clear lines distinguishing short COVID from medium and long COVID, entry and exit into these various groups is easy to over- or underestimate. What few data exist on the likelihood of recovery or remission is inconsistent, and not always rosy: Investigators of RECOVER, a large national study of long COVID, have calculated that about two-thirds of the long-haulers in their cohort do not return to baseline health. Putrino, who has worked with hundreds of long-haulers since the pandemic began, estimates that although most of his patients experience at least some benefit from a few months of rehabilitation, only about one-fifth to one-quarter of them eventually reach the point of feeling about as well as they did before catching the virus, while the majority hit a middling plateau. A small minority of the people he has treated, he told me, never seem to improve at all.

    Letícia Soares, a long-hauler in Brazil who caught the virus near the start of the pandemic, falls into that final category. Once a disease ecologist who studied parasite transmission in birds, she is now mostly housebound, working when she is able as a researcher for the Patient-Led Research Collaborative. Her days revolve around medications and behavioral modifications she uses for her fatigue, sleeplessness, and chronic pain. Soares no longer has the capacity to cook or frequently venture outside. And she has resigned herself to this status quo until the treatment landscape changes drastically. It is not the life she pictured for herself, Soares told me. “Sometimes I think the person I used to be died in April of 2020.”

    Even long-haulers who have noticed an improvement in their symptoms are wary of overconfidence. Some absolutely do experience what could be called recovery—but for others, the term has gotten loaded, almost a jinx. “If the question is, ‘Are you doing the things you were doing in 2019?’ the answer is largely no,” says JD Davids, a chronic-illness advocate based in New York. For some, he told me, “getting better” has been more defined by a resetting of expectations than a return to good health. Relapses are also not uncommon, especially after repeat encounters with the virus. Lisa McCorkell, a long-hauler and a co-founder of the Patient-Led Research Collaborative, has felt her symptoms partly abate since she first fell ill in the spring of 2020. But, she told me, she suspects that her condition is more likely to deteriorate than further improve—partly because of “how easy it is to get reinfected now.”

    Last week, in his State of the Union address, President Joe Biden told the American public that “we have broken COVID’s grip on us.” Highlighting the declines in the rates of COVID deaths, the millions of lives saved, and the importance of remembering the more than 1 million lost, Biden reminded the nation of what was to come: “Soon we’ll end the public-health emergency.”

    When the U.S.’s state of emergency was declared nearly three years ago, as hospitals were overrun and morgues overflowed, the focus was on severe, short-term disease. Perhaps in that sense, the emergency is close to being over, Deeks told me. But long COVID, though slower to command attention, has since become its own emergency, never formally declared; for the millions of Americans who have been affected by the condition, their relationship with the virus does not yet seem to be in a better place.

    Read: Trying to stop long COVID before it even starts

    Even with many more health-care providers clued into long COVID’s ills, the waiting lists for rehabilitation and treatment remain untenable, Hannah Davis told me. “I consider myself someone who gets exceptional care compared to other people,” she said. “And still, I hear from my doctor every nine or 10 months.” Calling a wrap on COVID’s “emergency” phase could worsen that already skewed supply-demand ratio. Changes to the nation’s funding tactics could strip resources—among them, access to telehealth; Medicaid coverage; and affordable antivirals, tests, and vaccines—from vulnerable populations, including people of color, that aren’t getting their needs met even as things stand, McCorkell told me. And as clinicians internalize the message that the coronavirus has largely been addressed, attention to its chronic impacts may dwindle. At least one of the country’s long-COVID clinics has, in recent months, announced plans to close, and Davis worries that more could follow soon.

    Scientists researching long COVID are also expecting new challenges. Reduced access to testing will complicate efforts to figure out how many people are developing the condition, and who’s most at risk. Should researchers turn their scientific focus away from studying causes and cures for long COVID when the emergency declaration lifts, Davids and others worry that there will be ripple effects on the scientific community’s interest in other, neglected chronic illnesses, such as ME/CFS (myalgic encephalomyelitis or chronic fatigue syndrome), a diagnosis that many long-haulers have also received.

    The end of the U.S.’s official crisis mode on COVID could stymie research in other ways as well. At Johns Hopkins University, the infectious-disease epidemiologists Priya Duggal, Shruti Mehta, and Bryan Lau have been running a large study to better understand the conditions and circumstances that lead to long COVID, and how symptoms evolve over time. In the past two years, they have gathered online survey data from thousands of people who both have and haven’t been infected, and who have and haven’t seen their symptoms rapidly resolve. But as of late, they’ve been struggling to recruit enough people who caught the virus and didn’t feel their symptoms linger. “I think that the people who are suffering from long COVID will always do their best to participate,” Duggal told me. That may not be the case for individuals whose experiences with the virus were brief. A lot of them “are completely over it,” Duggal said. “Their life has moved on.”

    Kate Porter, a Massachusetts-based marketing director, told me that she worries about her family’s future, should long COVID fade from the national discourse. She and her teenage daughter both caught the virus in the spring of 2020, and went on to develop chronic symptoms; their experience with the disease isn’t yet over. “Just because the emergency declaration is expiring, that doesn’t mean that suddenly people are magically going to get better and this issue is going to go away,” Porter told me. After months of relative improvement, her daughter is now fighting prolonged bouts of fatigue that are affecting her school life—and Porter isn’t sure how receptive people will be to her explanations, should their illnesses persist for years to come. “Two years from now, how am I going to explain, ‘Well, this is from COVID, five years ago’?” she said.

    A condition that was once mired in skepticism, scorn, and gaslighting, long COVID now has recognition—but empathy for long-haulers could yet experience a backslide. Nisreen Alwan, a public-health researcher at the University of Southampton, in the U.K., and her colleagues have found that many long-haulers still worry about disclosing their condition, fearing that it could jeopardize their employment, social interactions, and more. Long COVID could soon be slated to become just one of many neglected chronic diseases, poorly understood and rarely discussed.

    Davis doesn’t think that marginalization is inevitable. Her reasoning is grim: Other chronic illnesses have been easier to push to the sidelines, she said, on account of their smaller clinical footprint, but the pool of long-haulers is enormous—comprising millions of people in the U.S. alone. “I think it’s going to be impossible to ignore,” she told me. One way or another, the world will have no choice but to look.

    Katherine J. Wu

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  • The Glory of Feeling Fine

    The Glory of Feeling Fine

    A few months ago, I got food poisoning. The sequence of events that led to my downfall began with a carton of discounted grocery-store sushi purchased and consumed on a Thursday, which led to me waking up a little queasy on a Friday, which devolved into a 12-hour stretch of me vomiting and holding myself in a fetal position, until my legs ached from dehydration. On Saturday the smell of my partner cooking breakfast still made me gag; I sipped water, napped fitfully, and nibbled little golf balls of white rice.

    But Sunday, glorious Sunday, I awoke to a marvelous lack of pain and fatigue. The brain fog was gone. My skin felt plump with fluids. Enthralled by recovery, I found myself behaving with uncharacteristic serenity. When I dropped and broke a ceramic bowl while unloading the dishwasher, I didn’t curse and freak out. Instead, I swept up the shards with cheer. I wouldn’t sweat the small stuff. I was my normal self again, and it felt sublime.

    Yet as I relished in my newfound bliss, a foreboding thought gnawed at me: I knew that as the hours passed and the specter of illness retreated, my fresh perspective, too, would fade. So much of my exuberance was defined by absence, the lifting of the burden of aches and puking. It would only be a matter of time until normal felt normal again, and I’d be back to worrying about all the petty minutiae I always worry about.

    People have different baselines of health, and some might be more or less appreciative of whatever condition they’re in. Even so, humans have long lamented the ephemeral joy of relief. The feeling manifests in all kinds of circumstances: meeting a deadline, passing a test, finishing a marathon. And it can be especially acute in matters of wellness. “Health is not valued, till sickness comes,” wrote the 17th-century British scholar Thomas Fuller. Or as the 19th-century German philosopher Arthur Schopenhauer bemoaned: “Just as we do not feel the health of our entire body but only the small place where the shoe pinches, so too we do not think of the totality of our well-functioning affairs, but of some insignificant trifle that annoys us.”

    So many of us, in other words, are very bad at appreciating good health when we’re fortunate enough to have it. And anyone experiencing this transcendent gratitude is unlikely to hold on to it for long. Indeed, by Monday morning, the afterglow of recovery had worn off; I was engrossed in emails and work again, unaware that just 60 hours prior I could barely sit upright in bed, let alone at my desk. This troubled me. Am I cursed to be like this forever? Or is there anything I can do to change?

    To some extent, I’m sad to report, the answer might well be no. While certainly some people can have experiences of major illness or injury that change their entire outlook on life, the tendency to revert to forgetfulness seems to run pretty deep in the human psyche. We have limited attentional resources, the UC Davis psychology professor Robert Emmons told me, so in the interest of survival, our brain tends not to waste them focusing on systems that are working well. Instead, our mind evolved to identify threats and problems. Psychologists call this negativity bias: We direct our attention more to what’s wrong than what’s right. If your body’s in check, your brain seems to reason, better to stress about the project that’s overdue or the conflict with your friend than sit around feeling like everything’s fine.

    Read: Does ‘counting your blessings’ work?

    A second psychological phenomenon that might work against any enduring joy in recovery from illness is hedonic adaptation, the notion that after positive or negative life events we, basically, get used to our new circumstances and return to a baseline level of subjective well-being. Hedonic adaptation has been used to explain why, in the long term, people who won the lottery were no happier than those who didn’t; and why romantic partners lose passion, excitement, and appreciation for each other over time.

    Arguably, adaptation need not be seen as any great tragedy. For health, in particular, there’s an element of practicality in the human capacity to exist without fussy attentiveness. This is how we’re supposed to operate. “If our body isn’t causing us problems, it doesn’t actually pay to walk around being grateful all the time. You should be using your mental energy on other things,” Amie Gordon, an assistant professor of psychology at the University of Michigan, told me. If we had to sense our clothes on our bodies all day, for example, we’d constantly be distracted, she said. (This is actually a symptom of certain chronic disorders, like fibromyalgia—Lauren Zalewski, a writer who was diagnosed with both fibromyalgia and lupus 22 years ago, told me that it makes her skin sensitive to the touch, as if she constantly has the flu.)

    All that said, there are real costs to taking health for granted. For one, it can make you less healthy, if as a result you don’t take care of yourself. For another, maintaining some level of appreciation is a good way to avoid becoming an entitled jerk. Throughout the pandemic, for instance, there has been “this language around how the ‘only’ people dying are ‘old people’ or people with pre-existing conditions,” as if these deaths were more acceptable, Emily Taylor, a vice president for the Long-COVID Alliance, a group that advocates for research into post-viral illnesses, told me. Acknowledging that our own health is tenuous—and that certainly, many of us are going to get old—could counter this kind of callousness and encourage people to treat the elderly and those with chronic conditions or disabilities with more respect and kindness, Taylor argued.

    In my view, there’s something to be gained on an individual level, too. In recent years I’ve seen friends and loved ones deal with life-altering injuries and diagnoses. I know that one’s circumstances can turn on a phone call or a moment of inattention. To be healthy, to have basic needs met—to have life be so “normal” that it’s even a little boring—is a luxury. While I am living in those blessedly unremarkable times, I don’t want my fortune to escape my notice. When things are good, I want to know how good I’ve got it.

    Read: How to be thankful when you don’t feel thankful

    What I want, really, is to hold on to a sense of gratitude. In the field of psychology, gratitude can be something of a loaded term. Over the past decade or so, articles, podcast episodes, self-help books, research papers, celebrities, and wellness influencers alike have all extolled the benefits of being thankful. (Oprah famously kept a gratitude journal for more than a decade.) At times, gratitude’s popularity has been to its own detriment: The modern-day gratitude movement has been criticized for overstating its potential benefits and pushing a Western, wealthy, and privileged perspective that can seem to ignore the realities of extreme suffering or systemic injustices. It’s also annoying to constantly be told that you should really be more thankful for stuff.

    But part of the reason gratitude has become such a popular concept is due to bountiful research that does point to genuine emotional upsides. Feeling grateful has been associated with better life satisfaction, an increased sense of well-being, and a greater ability to form and maintain relationships, among other benefits. (The research on gratitude’s effects on physical health is inconclusive.) For me, though, the pull is less scientific and more commonsense anyway: Learning to genuinely appreciate day-to-day boons like having good health, or food in the fridge, seems like being able to tap into a renewable source of contentment. It’s always so easy to find stress in life. Let me remember the things to smile about, too.

    One way to make the most of gratitude may be to reframe how people tend to think of it. A popular misconception, Emmons told me over email, is that gratitude is a positive emotion that results from something good happening to us. (This might also be part of the reason it can be hard to appreciate conditions like health that for many people remain stable day after day.) Gratitude is an emotion, but it can also be a disposition, something researchers call “trait gratitude.” Some people are more predisposed to feeling thankful than others, by virtue of factors like genetics and personality. But Emmons says this kind of “undentable thankfulness” can also be learned, by developing habits that contribute to more of a persistent, ambient awareness, rather than a conditional reaction to ever-changing circumstances.

    What does this look like, practically speaking? “I don’t know that we can, with every breath we have every moment, feel grateful that we’re breathing. That’s a pretty tall order,” says Gordon. “But that’s not to say that you don’t build in a moment for it at some point in your day.” If you’re recovering from a cold, for example, you can practice pausing whenever you’re walking out the door to appreciate that your nose isn’t stuffy before just barreling on with life. Another tactic, from Emmons, is to reflect upon your worst moments, such as times you’ve been ill. “Our minds think in terms of counterfactuals,” he said, which are comparisons between the way things are and how they might have been. “When we remember how difficult life used to be and how far we have come, we set up an explicit contrast in our mind, and this contrast is fertile ground for gratefulness.”

    Read: Don’t teach your kids to fear the world

    You can also think of gratitude as an action, Emmons has written. This hews closer to the historical notion of gratitude, which as far back as the Roman days was associated with ideas like duty and reciprocity—when someone does something kind for us, we’re expected to return the favor, whether that’s thanking them, paying them back, or paying it forward. In that sense, being grateful for your body probably means doing your best to care for it (and, probably, refraining from risky behaviors like rolling the dice on discounted grocery-store sushi).

    In 2015, Lauren Zalewski, the writer with fibromyalgia, founded an online community that supports people living with chronic pain by helping them to cultivate a grateful mindset. She tells me that before her diagnosis, she took her health for granted and “beat her body up.” Now, she eats vegan, takes supplements, does yoga, stretches, sleeps more, and gets sun regularly—these are the small things she has personally found helpful for managing her constant pain. “So while I am a chronically ill person,” she muses, “I consider myself pretty healthy.”

    Looking back on my food-poisoning incident, I think I was primed to ruminate more deeply than usual on the topics of sickness and health. In the past two and a half years, I’ve watched COVID-19 show that anyone can get ill, perhaps seriously so. Now, as the head of the World Health Organization tells us that “the end is in sight” for the pandemic  (and President Joe Biden controversially declares the pandemic over), it’s tempting to imagine that humanity is on the brink of waking up the morning after a hellish sickness.

    It’s probably delusional to hope that even a global pandemic could prompt some kind of long-term collective mental shift about the impermanence of health, and of life. I didn’t become a radically different person after recovering from puking my guts out a few months ago either. But maybe the simple act of remembering the health we still have in the pandemic’s wake can make a small difference in how we go forward—if not as a society, then at least as individuals. I’m sure I’ll never fully override my tendency to take my body for granted until it’s too late. But for now, each day, I still get the golden opportunity to try. And I’d like to take it.

    Gloria Liu

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