Tag: news reports

The Grumpy Economy

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What was the worst moment for the American economy in the past half century? You might think it was the last wheezing months of the 1970s, when oil prices more than doubled, inflation reached double digits, and the U.S. sank into its second recession of the decade. Or the 2008 financial collapse and Great Recession. Or perhaps it was when COVID hit and millions of people abruptly lost their job. All good guesses—and all wrong, if surveys of the American public are to be believed. According to the University of Michigan Surveys of Consumers, the most widely cited measure of consumer sentiment, that moment was actually June 2022.

Inflation hit 9 percent that month, and no one knew if it would go higher still. A recession seemed imminent. Objectively, it’s hard to claim that the economy was in worse shape that month than it had been at those other cataclysmic times. But substantial pessimism was nonetheless explicable.

Over the next 18 months, however, the economy improved rapidly, and in nearly every way: Inflation plummeted to near its pre-pandemic level, unemployment reached historic lows, GDP boomed, and wages rose. The turnaround, by most standard economic measures, was unprecedented. Yet the American people continued to give the economy the kind of approval ratings traditionally reserved for used-car salesmen. Last June, the White House launched a campaign to celebrate “Bidenomics”—the administration’s strong job-creation record and big investments in manufacturing and clean energy. The effort flopped so badly that, within months, Democrats were begging the president to abandon it altogether.

Some kind of irreconcilable difference seemed to have opened up between public opinion and traditional markers of economic health, as many op-eds and news reports noted. “The Economy Is Great. Why Are Americans in Such a Rotten Mood?” The Wall Street Journal asked in early November. “What’s Causing ‘Bad Vibes’ in the Economy?” The New York Times wondered a few weeks later. Terms like “vibecession” and “the great disconnect” were coined and spread.

More recently, consumer sentiment has improved. After falling for months, it suddenly rebounded in December and January, posting its largest two-month gain in more than 30 years—even though the economy itself barely changed at all. Yet as of this writing, sentiment remains low by historical standards—nothing like the sunny outlook that prevailed before the pandemic.

What’s going on? The question involves the psychology of money—and of politics. Its answer will shape the outcome of the presidential election
in November.

The toll of inflation on the American psyche is undoubtedly part of the story. That people hate high inflation is not a novel observation: The Federal Reserve has long been obsessed with preventing another ’70s-style inflationary spiral; its patron saint is Paul Volcker, the former Fed chair who famously broke that spiral by jacking up interest rates, which plunged the economy into a recession. But although experts and political leaders know that inflation matters, the way they understand the phenomenon is very different from how ordinary people experience it—and that alone may explain why sentiment stayed low for so long, and has only now begun to rise.

When economists talk about inflation, they are often referring to an index of prices meant to represent the goods and services a typical household buys in a year. Each item in the index is weighted by how much is spent on it annually. So, for instance, because the average household spends about a third of its income on housing, the price of housing (an amalgam of rents and home prices) determines a third of the inflation rate. But the goods that people spend the most money on tend to be quite different from those that they pay the most attention to. Consumers are reminded of the price of food
every time they visit a supermarket or restaurant, and the price of gas is plastered in giant numbers on every street corner. Also, the purchase of these items can’t be postponed. Things like a new couch or flatscreen TV, in contrast, are purchased so rarely that many people don’t even remember how much they paid for one, let alone how much they cost today.

The irony is that consumers spend a lot more, on average, on expensive, big-ticket items than they do on groceries or takeout, which means the prices we pay the most attention to don’t contribute very much to overall inflation numbers. (Less than a tenth of the average consumer’s budget is spent at the supermarket.) Some measures of inflation—“core” and “supercore” inflation among them—exclude food and energy prices altogether. That is reasonable if you’re a Fed official focused on how to set interest rates, because energy and food prices are often extremely sensitive to temporary fluctuations (caused by, say, a drought that hurts grain harvests or an OPEC oil-supply cut). But in practice, these measures overlook the prices that matter most to consumers.

This dynamic alone goes a long way toward explaining the gap between “the economy” and Americans’ perception of it. Even as core inflation fell below 3 percent over the course of 2023, food prices increased by about 6 percent, twice as fast as they had grown over the previous 20 years. “I think that explains a huge part of the disconnect,” Paul Donovan, the chief economist at UBS Global Wealth Management, told me. “You won’t convince any consumer that inflation is under control when food prices are rising that fast.”

Consumers say as much when you ask them. In a recent poll commissioned by The Atlantic, respondents were asked what factors they consider when deciding how the national economy is doing. The price of groceries led the list, and 60 percent of respondents placed it among their top three—more, even, than the share that chose “inflation.” This isn’t exactly a new development. In 2002, Donovan told me, Italian consumers were convinced that prices were soaring by nearly 20 percent even though actual inflation was a stable 2 percent. It turned out that people were basing their estimates on the cost of a cup of espresso, which had abruptly risen as coffee makers rounded their prices up after the introduction of the euro.

Gilad Edelman: The English-muffin problem

What’s more, most people don’t care about the inflation rate so much as they care about prices themselves. If inflation runs at 10 percent for a year, and then suddenly shrinks to 2 percent, the damage of the past year has not been undone. Prices are still dramatically higher than they were. Overall, prices are nearly 20 percent higher now than they were before the pandemic (grocery prices are 25 percent higher). When asked in a survey last fall what improvement in the economy they would most like to see, 64 percent of respondents said “lower prices on goods, services, and gas.”

To fully embrace the economy’s strength would be to sacrifice part of the modern progressive’s ideological sense of self.

What about wages? Even adjusted for inflation, they have been rising since June 2022, and recently surpassed their pre-pandemic levels, meaning that the typical American’s paycheck goes further than it did prior to the inflation spike. But wages haven’t increased faster than food prices. And most people think about wage and price increases very differently. A raise tends to feel like something we’ve earned, Betsey Stevenson, an economist at the University of Michigan, told me. Then we go to the grocery store, and “it feels like those just rewards are being unfairly taken away.”

If inflation is in fact the main reason the American people have been so down on the economy—and its future—then the story is likely to have a happy ending, and soon. My great-grandmother loved to reminisce about the days when a can of Coke cost a nickel. She didn’t, however, believe that the country was on the verge of economic calamity because she now had to spend a dollar or more for the same beverage. Just as surely as people despise price increases, we also get used to them in the end. A recent analysis by Ryan Cummings and Neale Mahoney, two Stanford economists and former policy advisers in the Biden administration, found that it takes 18 to 24 months for lower inflation to fully show up in consumer sentiment. “People eventually adjust,” Mahoney told me. “They just don’t adjust at the rate that statistical agencies produce inflation data.”

Mahoney and Cummings posted their study on December 4, 2023—18 months after inflation peaked in June 2022. As if on cue, consumer sentiment began surging that month. (Perhaps helping matters, food inflation had finally fallen below 3 percent in November 2023.)

There is another story you can tell about consumer sentiment today, however, one that has less to do with what’s happening in grocery stores and more to do with the peculiarities of tribal identity.

It’s well established that partisans on both sides become more negative about the economy when the other party controls the presidency, but this phenomenon is not symmetrical: In a November analysis, Mahoney and Cummings found that when a Democrat occupies the White House, Republicans’ economic outlook declines by more than twice as much as Democrats’ does when the situation is reversed. Consumer-sentiment data from the polling firm Civiqs and the Pew Research Center show that Republicans’ view of the economy has barely budged since hitting an all-time low in the summer of 2022.

Meanwhile, although sentiment among Democrats has recovered to nearly where it stood before inflation began to rise in 2021, it remains well below its level at the end of the Obama administration. It may never return to its previous heights. Over the past decade, the belief that the economy is rigged in favor of the rich and powerful has become central to progressive self-identity. Among Democrats ages 18 to 34, who tend to be more progressive than older Democrats, positive views of capitalism fell from 56 to 40 percent between 2010 and 2019, according to Gallup. Dim views of the broader economic system may be limiting how positively some Democrats feel about the economy, even when one of their own occupies the Oval Office. According to a CNN poll in late January, 63 percent of Democrats ages 45 and older believed that the economy was on the upswing—but only 35 percent of younger Democrats believed the same. To fully embrace the economy’s strength would be to sacrifice part of the modern progressive’s ideological sense of self.

The media may be contributing to economic gloom for people of every political stripe. According to Mahoney, one possible explanation for Republicans’ disproportionate economic negativity when a Democrat is in office is the fact that the news sources many Republicans consume—namely, right-wing media like Fox News—tend to be more brazenly partisan than the sources Democrats consume, which tend to be a balance of mainstream and partisan media. But mainstream media have also gotten more negative about the economy in recent years, regardless of who’s held the presidency. According to a new analysis by the Brookings Institution, from 1988 to 2016, the “sentiment” of economic-news coverage in mainstream newspapers tracked closely with measures such as inflation, employment, and the stock market. Then, during Donald Trump’s presidency, coverage became more negative than the economic fundamentals would have predicted. After Joe Biden took office, the gap widened. Journalists have long focused more on surfacing problems than on highlighting successes—bringing problems to light is an essential part of the job—but the more recent shift could be explained by the same economic pessimism afflicting many young liberals (many newspaper journalists, after all, are liberals themselves). In other words, the media’s negativity could be both a reflection and a source of today’s economic pessimism.

What happens to consumer sentiment in the coming months will depend on how much it is still being dragged down by frustration with higher prices, which will likely dissipate, as opposed to how much it is being limited by a combination of Republican partisanship and Democratic pessimism, which are less likely to change.

Will the place that it finally settles in come November matter to the election? How people say they are feeling about the economy in an election year—alongside more direct measures of economic health, such as GDP growth and disposable income—has in the past been a good predictor of whom voters choose as president; a healthy economy and good sentiment strongly favor the incumbent. Despite all the abnormalities of 2020—a pandemic, national protests, a uniquely polarizing president—economic models that factored in both economic fundamentals and sentiment predicted the result and margin of that year’s presidential election quite accurately (and much more so than polling), according to an analysis by the political scientists John Sides, Chris Tausanovitch, and Lynn Vavreck.

It is of course possible that consumer sentiment is becoming a more performative metric than it used to be—a statement about who you are rather than how you really feel—and perhaps less reliable as a result. Still, the story that voters have in their heads about the economy clearly matters. If that story were influenced solely by the prices at the pump and the grocery store or the number of well-paying jobs, then—absent another crisis—we could expect the mood to be buoyant this fall, significantly helping Biden’s prospects for reelection. But the stories we tell ourselves are shaped by everything from the news we read to the political messages we hear to the identities we adopt. And, for better or worse, those stories have yet to be fully written.

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Rogé Karma

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February 14, 2024
Elise Stefanik’s Trump Audition

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Elise Stefanik and I had been speaking for only about a minute when she offered this stark self-assessment: “I have been an exceptional member of Congress.”

Her confidence reminded me of the many immodest pronouncements of Donald Trump (“I would give myself an A+”), and that’s probably not an accident. Stefanik has been everywhere lately, amassing fans among Trump’s base at a crucial moment—both for the GOP and for her future.

Stefanik spent October presiding over the leaderless House GOP’s search for a new speaker—a post that Stefanik, the chair of the conference, conspicuously declined to seek for herself. In a congressional hearing last month, she pressed three of America’s most prominent university presidents to say whether they’d allow students to call for Jewish genocide; directly or indirectly, her interrogation brought down two of them. And for the past several weeks, Stefanik has been making an enthusiastic case for Donald Trump’s return to the White House.

She campaigned with him in New Hampshire last weekend, defending his mental acuity in the face of obvious gaffes (“President Trump has not lost a step,” she insisted) and rejecting a jury’s conclusion that he sexually abused E. Jean Carroll. She parrots his baseless claims that the 2020 election was “rigged” and that the defendants charged with storming the Capitol to keep him in office are “hostages.” After a GOP congressional candidate was caught on tape mildly criticizing Trump, Stefanik publicly withdrew her endorsement. Barely an hour after the networks declared Trump the winner of the Iowa caucus—before Iowans had even finished voting—she issued a statement calling on his remaining opponents to drop out of the race.

I spoke with Stefanik about her fierce defense of Trump, which has won her praise from the former president. In New Hampshire, he called her “brilliant” and lauded her questioning of the university presidents as “surgical.” (He did, however, butcher her name.) Just about everyone can see that Stefanik has been mounting an elaborate audition. The 39-year-old clearly didn’t pass up a bid for House speaker because she lacks ambition. On the contrary, she seems to have a bigger promotion in mind: not second in line to the presidency, but first. In our conversation, Stefanik didn’t make much effort to dispel the perception that she wants to be Trump’s running mate. “I’d be honored to serve in any capacity in the Trump administration,” she told me, repeating a line she’s used before.

Her displays of fealty aside, Stefanik has a lot going for her. She has become, without question, the most powerful Republican in New York, where her prodigious fundraising helped give the GOP a majority. Stefanik’s House GOP colleagues say she is extremely smart, and she still draws compliments for her behind-the-scenes role during last fall’s speakership crisis, when she ran a tense and seemingly endless series of closed-door conference meetings. Whether or not her declining to run for speaker was tied to the vice presidency, it was politically shrewd. “It didn’t work out well for most others,” joked Representative Patrick McHenry of North Carolina, who briefly served as acting speaker and similarly turned down a chance to win the job permanently. “She saw the writing on the wall,” a fellow New York Republican, Representative Andrew Garbarino, told me. “She was smart enough to say, ‘I’m not popping my head up only to get it chopped off.’”

The fervor that Stefanik brings to her Trump defense has made her a favorite for VP among some of his staunchest allies, including Steve Bannon, who remains a force in MAGA world. “She’s a show horse and a workhorse, and that in and of itself is pretty extraordinary in modern American politics,” Bannon told me. “She’s at, if not the top, very close to the top of the list.”

Stefanik may not be subtle, but she’s made herself relevant in a party still devoted to Trump. Her future success now depends on his—and whether he rewards her loyalty with the prize she so clearly wants.

Stefanik routinely boasts that she was the first member of Congress to endorse Trump’s reelection. That’s true as far as 2024 goes, but it neatly obscures the fact that she did not back his primary campaign in 2016. Nor did she show much support for Trump’s movement as it took root in the GOP.

After graduating from Harvard, Stefanik began her political career in the George W. Bush White House and later served as an aide to Paul Ryan during his vice-presidential run. In 2014, at age 30, she was elected to the House—the youngest woman ever elected to Congress at the time—and carved out a reputation as a moderate in both policy and tone. She made an abrupt turn toward Trumpism during the former president’s first impeachment hearings, in 2019, and eagerly backed his reelection the following year. In 2021, she replaced the ousted Trump critic Representative Liz Cheney as conference chair, making her the fourth-ranking Republican in the House.

Read: A rising Republican’s bet on a losing president

Not one for public introspection, Stefanik has never fully explained her transformation into a Trump devotee beyond saying she was impressed by his policies as president. The simplest answer is that she followed the will of her upstate–New York constituents, who came to embrace Trump after favoring Barack Obama in 2008 and 2012. “I reflect, I would say, the voters in my district,” she told me shortly before the 2020 election.

To say that Stefanik displays the zeal of a convert doesn’t do justice to the phrase. She has become one of Trump’s foremost defenders and enforcers in Congress. At first “it was surprising,” former Representative Adam Kinzinger, a Republican colleague of Stefanik’s for eight years, told me of her Trump pivot. “Now it’s just gross.”

Kinzinger and Stefanik had both served as leaders of a group of moderate House Republicans, but they took opposite paths during the Trump years. Kinzinger voted to impeach Trump after January 6 and left Congress two years later. “In her core, she’s a deep opportunist and has put her personal ambition over what she knows is good for the country,” Kinzinger said. Although Stefanik has been in Trump’s corner for more than four years now, Kinzinger said she “has ramped up her sycophancy” as the chances of Trump’s renomination—and the possibility of her serving on the national ticket—have come more fully into view.

Close allies of Stefanik naturally dispute this characterization; they told me that although they think she’d make an excellent vice president, she has not once brought up the topic with them. “He’s going to have great options, but Elise will be at the top of that list,” Majority Leader Steve Scalise told me. When I asked Stefanik whether she was campaigning to be on Trump’s ticket, she replied: “I’m focused on doing my job.”

Other contenders frequently mentioned as possible Trump running mates include South Dakota Governor Kristi Noem; Arkansas Governor Sarah Huckabee Sanders, who served as one of Trump’s White House press secretaries; Senator Tim Scott of South Carolina; and the businessman Vivek Ramaswamy.

One senior Republican who is friendly with both Stefanik and Trump lauded her leadership skills and political acumen but doubted that Trump would pick her. “She doesn’t have executive experience,” the Republican told me, speaking on the condition of anonymity to talk candidly about Stefanik’s chances. A Trump-campaign spokesperson did not return a request for comment.

Even as they praise her, Stefanik allies occasionally describe her in ways that suggest she lacks authenticity. “She’s a highly intelligent, calculated individual,” Chris Tague, a Republican in the New York legislature, told me. Representative Marc Molinaro, a member of New York’s House delegation, described Stefanik as “a calming force” inside a House Republican conference often marred by infighting. When I noted that this characterization seemed to be at odds with her combative style in public, Molinaro explained that Stefanik’s “outward persona” helps her keep the conference from getting out of hand. “We all know Elise. She’s strong. She’s tough,” he said. “She didn’t need to be that person, because we know she can be that person.”

Still, Kinzinger said, unlike some Republicans in Congress, Stefanik does not speak differently about Trump in private than she does in public. “I got that wink and nod from a lot of people, not from her,” he said. “She’s smart enough to know that if she says something in private, it could get out.”

Stefanik is also smart enough, Kinzinger told me, to understand that Trump’s claims about the 2020 election, which she now recites, are not true. “She knows the drill,” he said. “She would say exactly what I would say if she had the freedom to do it, but she’s all in.”

To interview Stefanik is to strike a sort of deal: access in exchange for browbeating. She answered my questions even as she rebuked me for asking about such trifling matters as election denialism and January 6. “Everyday Americans are sick and tired of the biased media, including you, Russell, and the types of questions you’re asking,” Stefanik told me. I started to ask her about her recent appearance on Meet the Press, where she had casually referred to the January 6 defendants as “hostages”—an unsubtle echo of Trump’s language. The comment prompted a predictable round of shocked-but-not-surprised reactions from Democrats and anti-Trump Republicans. A New York Democrat, Representative Dan Goldman, introduced a resolution to censure Stefanik over the remark.

Read: The governor who wants to be Trump’s next apprentice

Even though Stefanik made a show of protesting my line of inquiry, she beat me to the question. I had barely uttered “Meet the Press … ” before she started speaking over me: “I know—you’re so predictable—what you’re going to ask. You’re going to ask about the January 6 hostages.” Bingo. Without missing a beat, Stefanik proceeded to read aloud snippets from New York Times and NPR reports about poor conditions and alleged mistreatment of inmates charged with January 6 crimes. “The American people are smart. They see through this,” she said. “They know that there is a double standard of justice in this country.”

Stefanik was trying to argue that these news reports justified her use of a term usually reserved for victims of terrorism. The specifics of the reports weren’t really the point. More than anything, she seemed to want to demonstrate that, like Trump, she wouldn’t back down or apologize. She sounded almost cheerful, like a happy warrior for Trump—his pugnacious defender who would engage with the biased mainstream media without giving in to them, without conceding a single premise or hemming and hawing through an interview.

Stefanik was riding high in MAGA world when we spoke. Her Meet the Press appearance was “a master class,” Bannon told me. In addition to the “hostages” line, she refused to commit to certifying the 2024 election, generating outrage that only added to the performance. “This is what we’re thinking. This is us. This is who we are,” Susan McNeil, a GOP county chair in Stefanik’s district, told me, referring to Stefanik’s comments about certification. “Do I trust this election right now? No.”

“For her to stand strong and make those statements? Good. You’re not being bullied,” McNeil continued. “You’re not gonna get pressured to cave in to saying something that you’re not ready to dignify with an answer yet.”

Stefanik has no interest in appearing humble or self-deprecating. When I brought up the Meet the Press interview, she used the same word that Bannon had to describe her performance. “It was a master class in pushing back” against the media, she told me, “and it has been widely hailed.”

Cooperating with this story, like appearing on the D.C. establishment’s favorite talk show, seemed to be part of Stefanik’s unofficial, unacknowledged audition for VP. It was a low-risk bet. A positive portrayal might impress the media-conscious Trump. If, on the other hand, she didn’t like how the piece turned out, she could hold it up to Trump supporters as confirmation that the press has it out for them. Stefanik’s team lined up nearly a dozen local and national validators to speak with me, including Bannon, Scalise, and Representative James Comer, who heads the committee leading the Biden-impeachment inquiry.

Trump clearly prizes loyalty above just about anything else. Mike Pence displayed that quality in spades, until suddenly, at the most climactic moment of Trump’s presidency, he did not. To test whether Stefanik’s allegiance had a limit, I asked whether a Trump conviction for any of the crimes with which he’s been charged would affect her support in any way. “No,” she replied without hesitation. “It’s a witch hunt by the Department of Justice. I believe Joe Biden is the most corrupt president not just in modern history, but in the history of our country.”

Stefanik was more circumspect when I asked her what she would have done differently from Pence had she been responsible, as vice president, for presiding over the certification of Electoral College ballots on January 6. Trump had pressured Pence to throw out ballots from states where he was contesting the vote. Pence had refused. Given Stefanik’s apparent interest in Pence’s old job, it seemed relevant.

At first, she dodged the question by claiming that the election was rigged and referring to a speech she delivered on the House floor in the early hours of January 7, when she voted against certifying Biden’s victory in Pennsylvania. But that speech was worded far more carefully than the outright claims of fraud that Stefanik makes today. Back then, she couched her objections as representing the views of her “concerned” constituents. She didn’t say the election was stolen, nor did she say what action Pence should have taken.

When I pressed her on Pence’s decision not to intervene and what she would have done, Stefanik replied simply, “I disagreed, and I believe it was an unconstitutional election.” She would go no further than that.

At some point over the next several months, Stefanik’s dual roles as Trump booster and protector of the vanishing House majority could come into conflict. She has made clear that she wants Republicans to unify around Trump, and sooner rather than later. Control of the House, however, might well be determined in her deep-blue state, where the nation’s most vulnerable Republicans represent districts that Trump lost in 2020. Embracing Trump this fall could cost some of them their seats.

Watch: The candidates running for vice president

Now the longest-serving Republican in the New York delegation, Stefanik serves as a mentor for several of the state’s more recent arrivals to the House. She has helped get them seats on desired committees, and, during the speaker battle in October, she arranged for the various candidates to sit for interviews with the delegation. But Stefanik has also worked to keep them in line.

“She’s not afraid to be blunt,” Garbarino said, recalling times when Stefanik chastised him for a public statement she didn’t like. Her message? “We don’t have to do everything publicly,” Garbarino said. “Sometimes it’s better if you say this stuff behind the scenes to somebody instead of smacking them in the face publicly about it.”

Stefanik has taken the lead in fighting Democratic attempts to gerrymander New York in their favor, part of an effort to reclaim the House majority. (A recent state-court ruling didn’t help her cause.) To that end, she is working to ensure that none of the state’s GOP House members tries to save their own seat at the party’s expense or says anything in public that could undermine a potential Republican legal challenge. “She’s cracking the whip,” one Republican strategist in the state told me, speaking on the condition of anonymity.

Stefanik’s toughest task, though, might be getting her colleagues to support Trump. Two swing-district Republicans in New York, Representatives Nick LaLota and Brandon Williams, have endorsed Trump as he easily captured the first two primary states. But others in the delegation have yet to heed Stefanik’s call. In interviews, a few of them seemed hesitant even to utter his name. “I have avoided presidential politics, and Elise has always respected that,” Molinaro told me. As for Trump, he would say only, “I intend to support the presidential nominee.”

Garbarino used almost exactly the same words when I asked about the presidential race. Two other New York Republicans in districts that Biden won, Representatives Mike Lawler and Anthony D’Esposito, declined interview requests. When I asked Stefanik if they would back Trump, she offered a guarantee: “They’re going to support President Trump, who will be the nominee, as Republicans will across the country.”

Privately, Stefanik has delivered an additional message to vulnerable Republicans in New York, according to several people I spoke with. “Stefanik has been very clear to not attack President Trump,” the GOP strategist said. “Everyone knows that in New York.” As Stefanik sees it, criticizing Trump would hurt even swing-district Republicans, because the MAGA base is now a sizable constituency in districts that Biden carried. Still, other House leaders haven’t exerted nearly as much public pressure on rank-and-file Republicans. “We all each individually take different approaches to growing our majority,” Scalise told me. “I don’t tell anybody how to manage their politics back home.”

As Stefanik’s profile has grown, and as her rhetoric has become even Trumpier, Democrats have sought to turn her into a political liability for swing-district Republicans, just as they have the former president. After Stefanik’s “hostages” comment, House Minority Leader Hakeem Jeffries, who also hails from New York, said that Stefanik “should be ashamed of herself.”

But then he pivoted to a political angle. “The real question,” Jeffries told reporters, “is why haven’t House Republicans in New York, like Mike Lawler or others, denounced Elise Stefanik, and why do they continue to rely on her fundraising support in order to try to fool the voters in New York and pretend like they believe in moderation?” None of the New York Republicans took the bait, choosing to remain silent rather than cross Stefanik. (“I didn’t see the clip,” Garbarino told me, in one characteristic dodge.)

Stefanik clearly welcomes these attacks. In the MAGA world she now inhabits, enraging Democrats is the coin of the realm. Taking their fire only pushes her closer to the place she really wants to be: at Trump’s side.

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Russell Berman

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January 25, 2024
Whatever Happened to Carpal Tunnel Syndrome?

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Diana Henriques was first stricken in late 1996. A business reporter for The New York Times, she was in the midst of a punishing effort to bring a reporting project to fruition. Then one morning she awoke to find herself incapable of pinching her contact lens between her thumb and forefinger.

Henriques’s hands were soon cursed with numbness, frailty, and a gnawing ache she found similar to menstrual cramps. These maladies destroyed her ability to type—the lifeblood of her profession—without experiencing debilitating pain.

“It was terrifying,” she recalls.

Henriques would join the legions of Americans considered to have a repetitive strain injury (RSI), which from the late 1980s through the 1990s seized the popular imagination as the plague of the modern American workplace. Characterized at the time as a source of sudden, widespread suffering and disability, the RSI crisis reportedly began in slaughterhouses, auto plants, and other venues for repetitive manual labor, before spreading to work environments where people hammered keyboards and clicked computer mice. Pain in the shoulders, neck, arms, and hands, office drones would learn, was the collateral damage of the desktop-computer revolution. As Representative Tom Lantos of California put it at a congressional hearing in 1989, these were symptoms of what could be “the industrial disease of the information age.”

By 1993, the Bureau of Labor Statistics was reporting that the number of RSI cases had increased more than tenfold over the previous decade. Henriques believed her workplace injury might have had a more specific diagnosis, though: carpal tunnel syndrome. Characterized by pain, tingling, and numbness that results from nerve compression at the wrist, this was just one of many conditions (including tendonitis and tennis elbow) that were included in the government’s tally, but it came to stand in for the larger threat. Everyone who worked in front of a monitor was suddenly at risk, it seemed, of coming down with carpal tunnel. “There was this ghost of a destroyed career wandering through the newsroom,” Henriques told me. “You never knew whose shoulder was going to feel the dead hand next.”

But the epidemic waned in the years that followed. The number of workplace-related RSIs recorded per year had already started on a long decline, and in the early 2000s, news reports on the modern plague all but disappeared. Two decades later, professionals are ensconced more deeply in the trappings of the information age than they’ve ever been before, and post-COVID, computer use has spread from offices to living rooms and kitchens. Yet if this work is causing widespread injury, the evidence remains obscure. The whole carpal tunnel crisis, and the millions it affected, now reads like a strange and temporary problem of the ancient past.

Read: Yes, the pandemic is ruining your body

So what happened? Was the plague defeated by an ergonomic revolution, with white-collar workers’ bodies saved by thinner, light-touch keyboards, adjustable-height desks and monitors, and Aeron chairs? Or could it be that the office-dweller spike in RSIs was never quite as bad as it seemed, and that the hype around the numbers might have even served to make a modest problem worse, by spreading fear and faulty diagnoses?

Or maybe there’s another, more disturbing possibility. What if the scourge of RSIs receded, but only for a time? Could these injuries have resurged in the age of home-office work, at a time when their prevalence might be concealed in part by indifference and neglect? If that’s the case—if a real and pervasive epidemic that once dominated headlines never really went away—then the central story of this crisis has less to do with occupational health than with how we come to understand it. It’s a story of how statistics and reality twist around and change each other’s shape. At times they even separate.

The workplace epidemic was visible only after specific actions by government agencies, employers, and others set the stage for its illumination. This happened first in settings far removed from office life. In response to labor groups’ complaints, the Occupational Safety and Health Administration began to look for evidence of RSIs within the strike-prone meatpacking industry—and found that they were rampant.

Surveillance efforts spread from there, and so did the known scope of the problem. By 1988, OSHA had proposed multimillion-dollar fines against large auto manufacturers and meatpacking plants for underreporting employees’ RSIs; other businesses, perhaps spooked by the enforcement, started documenting such injuries more assiduously. Newspaper reporters (and their unions) took up the story, too, noting that similar maladies could now be produced by endless hours spent typing at the by-then ubiquitous computer keyboard. In that way, what had started playing out in government enforcement actions and statistics morphed into a full-blown news event. The white-collar carpal tunnel crisis had arrived.

In the late 1980s, David Rempel, an expert in occupational medicine and ergonomics at UC San Francisco, conducted an investigation on behalf of California’s OSHA in the newsroom of The Fresno Bee. Its union had complained that more than a quarter of the paper’s staff was afflicted with RSIs, and Rempel was there to find out what was wrong.

The problem, he discovered, was that employees had been given new, poorly designed computer workstations, and were suddenly compelled to spend a lot of time in front of them. In the citation that he wrote up for the state, Rempel ordered the Bee to install adjustable office furniture and provide workers with hourly breaks from their consoles.

A computer workstation at The Fresno Bee in 1989 (Courtesy of David Rempel)

Similar injury clusters were occurring at many other publications, too, and reporters cranked out stories on the chronic pain within their ranks. More than 200 editorial employees of the Los Angeles Times sought medical help for RSIs over a four-year stretch, according to a 1989 article in that newspaper. In 1990, The New York Times published a major RSI story—“Hazards at the Keyboard: A Special Report”—on its front page; in 1992, Time magazine ran a major story claiming that professionals were being “Crippled by Computers.”

But ergonomics researchers like Rempel would later form some doubts about the nature of this epidemic. Research showed that people whose work involves repetitive and forceful hand exertions for long periods are more prone to developing carpal tunnel syndrome, Rempel told me—but that association is not as strong for computer-based jobs. “If there is an elevated risk to white-collar workers, it’s not large,” he said.

Read: Chronic pain is an impossible problem

Computer use is clearly linked to RSIs in general, however. A 2019 meta-analysis in Occupational & Environmental Medicine found an increased risk of musculoskeletal symptoms with more screen work (though it does acknowledge that the evidence is “heterogeneous” and doesn’t account for screen use after 2005). Ergonomics experts and occupational-health specialists told me they are certain that many journalists and other professionals did sustain serious RSIs while using 1980s-to-mid-’90s computer workstations, with their fixed desks and chunky keyboards. But the total number of such injuries may have been distorted at the time, and many computer-related “carpal tunnel” cases in particular were spurious, with misdiagnoses caused in part by an unreliable but widely used nerve-conduction test. “It seems pretty clear that there wasn’t a sudden explosion of carpal tunnel cases when the reported numbers started to go up,” Leslie Boden, an environmental-health professor at the Boston University School of Public Health, told me.

Such mistakes were probably driven by the “crippled by computers” narrative. White-collar workers with hand pain and numbness might have naturally presumed they had carpal tunnel, thanks to news reports and the chatter at the water cooler; then, as they told their colleagues—and reporters—about their disabilities, they helped fuel a false-diagnosis feedback loop.

It’s possible that well-intentioned shifts in workplace culture further exaggerated the scale of the epidemic. According to Fredric Gerr, a professor emeritus of occupational and environmental health at the University of Iowa, white-collar employees were encouraged during the 1990s to report even minor aches and pains, so they could be diagnosed—and treated—earlier. But Gerr told me that such awareness-raising efforts may have backfired, causing workers to view those minor aches as harbingers of a disabling, chronic disease. Clinicians and ergonomists, too, he said, began to lump any pain-addled worker into the same bin, regardless of their symptoms’ severity—a practice that may have artificially inflated the reported rates of RSIs and caused unnecessary anxiety.

Henriques, whose symptoms were consistent and severe, underwent a nerve-conduction test not long after her pain and disability began; the result was inconclusive. She continues to believe that she came down with carpal tunnel syndrome as opposed to another form of RSI, but chose not to receive surgery given the diagnostic uncertainty. New York Times reporters with RSIs were not at risk of getting fired, as she saw it, but of ending up in different roles. She didn’t want that for herself, so she adapted to her physical limitations, mastering the voice-to-text software that she has since used to dictate four books. The most recent came out in September.

As it happens, a very similar story had played out on the other side of the world more than a decade earlier.

Reporters in Australia began sounding the alarm about the booming rates of RSIs among computer users in 1983, right at the advent of the computer revolution. Some academic observers dismissed the epidemic as the product of a mass hysteria. Other experts figured that Australian offices might be more damaging to people’s bodies than those in other nations, with some colorfully dubbing the symptoms “kangaroo paw.” Andrew Hopkins, a sociologist at the Australian National University, backed a third hypothesis: that his nation’s institutions had merely facilitated acknowledgement—or stopped suppressing evidence—of what was a genuine and widespread crisis.

“It is well known to sociologists that statistics often tell us more about collection procedures than they do about the phenomenon they are supposed to reflect,” Hopkins wrote in a 1990 paper that compared the raging RSI epidemic in Australia to the relative quiet in the United States. He doubted that any meaningful differences in work conditions between the two nations could explain the staggered timing of the outbreaks. Rather, he suspected that different worker-compensation systems made ongoing epidemics more visible, or less, to public-health authorities. In Australia, the approach was far more labor-friendly on the whole, with fewer administrative hurdles for claimants to overcome, and better payouts to those who were successful. Provided with this greater incentive to report their RSIs, Hopkins argued, Australian workers began doing so in greater numbers than before.

Then conditions changed. In 1987, Australia’s High Court decided a landmark worker-compensation case involving an RSI in favor of the employer. By the late 1980s, the government had discontinued its quarterly surveillance report of such cases, and worker-comp systems became more hostile to them, Hopkins said. With fewer workers speaking out about their chronic ailments, and Australian journalists bereft of data to illustrate the problem’s scope, a continuing pain crisis might very well have been pushed into the shadows.

Now it was the United States’ turn. Here, too, attention to a workplace-injury epidemic swelled in response to institutional behaviors and incentives. And then here, too, that attention ebbed for multiple reasons. Improvements in workplace ergonomics and computer design may indeed have lessened the actual injury rate among desk workers during the 1990s. At the same time, the growing availability of high-quality scanners reduced the need for injury-prone data-entry typists, and improved diagnostic practices by physicians reduced the rate of false carpal tunnel diagnoses. In the blue-collar sector, tapering union membership and the expansion of the immigrant workforce may have pushed down the national number of recorded injuries, by making employees less inclined to file complaints and advocate for their own well-being.

But America’s legal and political climate was shifting too. Thousands of workers would file lawsuits against computer manufacturers during this period, claiming that their products had caused injury and disability. More than 20 major cases went to jury trials—and all of them failed. In 2002, the Supreme Court ruled against an employee of Toyota who said she’d become disabled by carpal tunnel as a result of working on the assembly line. (The car company was represented by John Roberts, then in private appellate-law practice.) Meanwhile, Republicans in Congress managed to jettison a new set of OSHA ergonomics standards before they could go into effect, and the George W. Bush administration ended the requirement that employers separate out RSI-like conditions in their workplace-injury reports to the government. Unsurprisingly, recorded cases dropped off even more sharply in the years that followed.

Read: When the computer mouse was new

Blue-collar workers in particular would be left in the lurch. According to M. K. Fletcher, a safety and health specialist at the AFL-CIO, many laborers, in particular those in food processing, health care, warehousing, and construction, continue to suffer substantial rates of musculoskeletal disorders, the term that’s now preferred over RSIs. Nationally, such conditions account for an estimated one-fifth to one-third of the estimated 8.4 million annual workplace injuries across the private sector, according to the union’s analysis of Bureau of Labor Statistics reports.

From what experts can determine, carpal tunnel syndrome in particular remains prevalent, affecting 1 to 5 percent of the overall population. The condition is associated with multiple health conditions unrelated to the workplace, including diabetes, age, hypothyroidism, obesity, arthritis, and pregnancy. In general, keyboards are no longer thought to be a major threat, but the hazards of repetitive work were always very real. In the end, the “crippled by computers” panic among white-collar workers of the 1980s and ’90s would reap outsize attention and perhaps distract from the far more serious concerns of other workers. “We engage in a disease-du-jour mentality that is based on idiosyncratic factors, such as journalists being worried about computer users, rather than prioritization by the actual rate and the impact on employment and life quality,” Gerr, the occupational- and environmental-health expert at the University of Iowa, told me.

As for today’s potential “hazards at the keyboard,” we know precious little. Almost all of the research described above was done prior to 2006, before tablets and smartphones were invented. Workplace ergonomics used to be a thriving academic field, but its ranks have dwindled. The majority of the academic experts I spoke with for this story are either in the twilight of their careers or they’ve already retired. A number of the researchers whose scholarship I’ve reviewed are dead. “The public and also scientists have lost interest in the topic,” Pieter Coenen, an assistant professor at Amsterdam UMC and the lead author of the meta–analysis from 2019, told me. “I don’t think the problem has actually resolved.”

So is there substantial risk to workers in the 2020s from using Slack all day, or checking email on their iPhones, or spending countless hours hunched at their kitchen tables, typing while they talk on Zoom? Few are trying to find out. Professionals in the post-COVID, work-from-home era may be experiencing a persistent or resurgent rash of pain and injury. “The industrial disease of the information age” could still be raging.

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Benjamin Ryan

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October 31, 2023
The Lifeguard Shortage Never Ends

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The United States, you may have heard, is in a lifeguard shortage. The city of Houston is offering new lifeguards a $500 bonus. Jackson, Mississippi, is raising lifeguard pay by more than 40 percent. Colorado is “stepping up” with $250,000 for hiring lifeguard reinforcements; in the meantime, senior citizens are filling in. According to the American Lifeguard Association, about half of the nation’s public pools will have to close or reduce their hours this summer because of a lack of staff.

The current shortage can be largely blamed on pandemic-era closures and work restrictions, according to news reports. But if that accounts for this year’s shortage as well as those reported in 2020, 2021, and 2022, it cannot explain the national lifeguard shortages of 2018, 2016, or 2012. Or, for that matter, a reported lifeguard shortage in 1984. Or 1951. Or 1926.

These crises—and the newspaper stories that describe them—are as much a summer tradition as boardwalks and ice cream. Local or national news articles on the subject have appeared in May or June of every single year of the 21st century. Hundreds more specimens of this perennial have been published since the 1930s. Each lays out the same basic claims: The swimming season might be compromised; drownings could increase. But few acknowledge that such claims were also made the year before, and in all the years before that. Indeed, the specter of a long, unguarded summer has haunted us for five generations now, about as long as there have been formally trained lifeguards in America.

The reasons given for the shortages have varied with the times. Now, of course, we have COVID. In the 1980s, authorities blamed Gen X demographics: “It’s happening because there simply aren’t as many 16-year-olds,” one told The New York Times. In the 1950s, they blamed the IRS: “Many lifeguards quit before earning $600 so their fathers can claim them as income tax dependents,” explained the Minneapolis Star Tribune. In the 1940s, experts said that the draft had roped in so many of the nation’s young men that, per The Baltimore Sun, some beaches and pools were “seriously considering employing women.” And in the 1930s, the shortage was attributed to the absorption of potential lifeguards into the Works Progress Administration.

But overall, the purported causes of shortages are remarkably repetitive and, in many cases, remarkably ahistoric.

The stringent requirements of lifeguarding—taking and paying for a multiday course to pass a tough physical exam—are a recurring scapegoat. So is low pay. In 1941, pool managers complained that young men who hadn’t been drafted could make much more working in defense industries than as a lifeguard. In 2007, a New Jersey lifeguard captain lamented to the Times that “iPods and cellphones are expensive … If kids are looking for the highest-paying job, it isn’t likely to be lifeguarding.” In that same article, a Connecticut parks official blamed the growing emphasis on career-building (and the concurrent rise of internships). The YMCA’s water-safety specialist also cited internships, in 2021. Any time unemployment is low, someone accuses it of contributing to the lifeguard shortage.

By far the most consistent explanations over the years can best be described as “kids these days.” See 1987: “The kids around here have too much money.” And 2015: “There is another big turnoff: having a phone on the lifeguard stand is a firing offense.” And 2019: “Some [teens] are even frightened of the lifesaving responsibility the job carries.” And 2022: “People just don’t want to do this kind of job.” And 2023: “Since COVID, people don’t want to work.” Wyatt Werneth, the national spokesperson for the American Lifeguard Association, told me this week that, after the pandemic arrived, people who might otherwise be lifeguard candidates began opting for jobs that could be done at home, such as “the influencing and social media and stuff like that.”

And then, of course, there’s the biggest problem of all: No one looks up to lifeguards anymore. From The New York Times in 1984: “Lifeguards were once authority figures, just like teachers once were. But the glory of the authoritarian age is gone.” In 1985, the Times wistfully recalled the lifeguard-loving cinema of the ’50s and ’60s (Beach Blanket Bingo and its ilk) and the reverence it once inspired. Robert A. Kerwin, the water-safety coordinator of the New Jersey State Division of Parks and Forestry, told the paper, “The day of the macho lifeguard sitting in the chair flexing his muscles is finished. For one thing, 25 percent of our guards are girls.” (For what it’s worth, Newspapers.com lists plenty of articles about lifeguard shortages from the ’50s and the ’60s too.)

Read: Imagining the jellyfish apocalypse

The Times once declared, “The lifeguard is an endangered species.” But its population recovered briefly in the 1990s, thanks to David Hasselhoff. “When I became a lifeguard,” Werneth said, “we had Baywatch, and everybody wanted to be a lifeguard. They wanted that lifestyle where you had helicopters and you had fast boats and beautiful people, and you’re saving lives.” But Baywatch: Hawaii ceased production in 2001, and after that, Werneth told me, “things started declining.” Lifeguard employment took a dip and then a swan dive starting in 2020. “I can almost call it a ground zero,” Bernard Fisher, the director of the American Lifeguard Association, said of the shortage in a 2022 Fox News article.

Despite the tenor of that analogy (Fisher also compared the lack of lifeguards to the lack of baby formula), drowning rates haven’t really spiked. In fact, they’re now a third of what they were in 1970, and have been dropping steadily for a century or more. (There was a very slight uptick in 2020 and 2021, the most recent years for which data are available.) In other words, the many lifeguard crises of the past—or perhaps the single, never-ending one—have not correlated with any widespread drowning crises in America. That does not mean that lifeguard shortages are fake, but hard data on their scope remain obscure. Werneth told me that the American Lifeguard Association receives “very sporadic” reports from pools, parks, and beaches, and has just a rough sense of the level of need in different regions.

But if the lifeguard is once again an endangered species, it’s still beloved: more like a giant panda than a Gerlach’s cockroach. As a culture, we do still think of lifeguards as sexy, heroic, and essential (if not authoritarian). Baywatch may be off the air, but it’s always coming back.

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Rachel Gutman-Wei

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June 9, 2023
What Doctors Still Don’t Understand About Long COVID

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As a pulmonary specialist, I spend most of my clinical time in the hospital—which, during pandemic surges, has meant many long days treating critically ill COVID-19 patients in the ICU. But I also work in an outpatient clinic, where I also treat those same sorts of patients after they’re discharged: people who survived weeks-long hospitalizations but have been dealing ever since with lung damage. Such patients often face the same social and economic factors that made them vulnerable to COVID-19 to begin with, and they require attentive care.

Patients like these undoubtedly suffer what researchers have been calling post-acute sequelae of SARS-CoV-2, or PASC—which, according to one highly publicized recent CDC study, afflicts some 20 percent of COVID-19 survivors ages 18 to 64. Other studies have yielded lower estimates of the condition also called long COVID, and while differences in study methodology account for some of this variability, there’s a more fundamental issue eluding efforts to uncover the one “true” estimate of the likelihood of this condition. Quite simply, long COVID isn’t any one thing.

From the April 2021 issue: Unlocking the mysteries of long COVID

The wide spectrum of conditions that fall under the umbrella of long COVID impedes researchers’ ability to interpret estimates of national prevalence based on surveys of symptoms, which conflate different problems with different causes. More importantly, however, an incomplete and constrained perspective on what long COVID is or isn’t limits Americans’ understanding of who is suffering and why, and of what we can do to improve patients’ lives today.

The cases of long COVID that turn up in news reports, the medical literature, and in the offices of doctors like me fall into a few rough (and sometimes overlapping) categories. The first seems most readily explainable: the combination of organ damage, often profound physical debilitation, and poor mental health inflicted by severe pneumonia and resultant critical illness. This serious long-term COVID-19 complication gets relatively little media attention despite its severity. The coronavirus can cause acute respiratory distress syndrome, the gravest form of pneumonia, which can in turn provoke a spiral of inflammation and injury that can end up taking down virtually every organ. I have seen many such complications in the ICU: failing hearts, collapsed lungs, failed kidneys, brain hemorrhages, limbs cut off from blood flow, and more. More than 7 million COVID-19 hospitalizations occurred in the United States before the Omicron wave, suggesting that millions could be left with damaged lungs or complications of critical illness. Whether these patients’ needs for care and rehabilitation are being adequately (and equitably) met is unclear: Ensuring that they are is an urgent priority.

Recently, a second category of long COVID has made headlines. It includes the new onset of recognized medical conditions—like heart disease, a stroke, or a blood clot—after a mild COVID-19 infection. It might seem odd that an upper respiratory tract infection could trigger a heart attack. Yet this pattern has been well described after other common respiratory-virus infections, particularly influenza. Similarly, various types of infections can lead to blood clots in the legs, which can travel (dangerously) to the lungs. Respiratory infections are not hermetically sealed from the rest of the body; acute inflammation arising in one location can sometimes have consequences elsewhere.

But mild COVID-19 is so common that measuring the prevalence of such complications—which also regularly occur in people without COVID-19—can be tricky. Well-controlled investigations are needed to disentangle causation and correlation, particularly because social disadvantage is associated both with COVID exposure and illnesses of basically every organ system. Some such studies, which analyzed giant electronic-health-record databases, have suggested that even mild COVID-19 is at least correlated with a startlingly wide spectrum of seemingly every illness, including diabetes, asthma, and kidney failure; basically every type of heart disease; alcohol-, benzodiazepine-, and opioid-use disorders; and much more.

To be clear, this research generally suggests that such complications occur far less often after mild COVID-19 cases than severe ones, and the extent to which the coronavirus causes each such complication remains unclear. In other words, we can surmise that at least some of these complications (particularly vascular complications, which have been well-described in many studies) are likely a consequence of COVID-19, but we can’t say with certainty how many. And more importantly, we don’t yet understand why some people with mild COVID recover easily while others go on to experience such complications. However, an estimated 81 percent of Americans have now been infected at least once, so the public-health ramifications are large even if COVID causes only some of the aforementioned recognized diseases, and even if our individual risk of complications after a mild infection is modest. Regardless of cause, patients who do develop any such chronic diseases require attentive, ongoing medical care—a challenge in a nation where 30 million are uninsured and even more underinsured.

Another category of long COVID is something rather more quotidian, if still very distressing for those experiencing it: respiratory symptoms that last longer than expected after an acute upper-respiratory infection caused by the coronavirus, but that are not associated with lung damage, critical illness, or a new diagnosis like a heart attack or diabetes. Symptoms such as shortness of breath and chest pain are common months after run-of-the-mill pneumonia unconnected to the coronavirus, for instance, while many patients who contract non-COVID-related upper respiratory infections subsequently report a protracted cough or a lingering loss of their sense of smell. That a COVID-related airway infection sometimes has similar consequences only stands to reason.

Read: Long-haulers are fighting for their future

However, none of these may be what most people think of when long COVID is invoked. Some may even argue that such syndromes are not, in fact, long COVID at all, even if they cause long-term suffering. “Long Covid is not a condition for which there are currently accepted objective diagnostic tests or biomarkers,” wrote Steven Phillips and Michelle Williams in the New England Journal of Medicine. “It is not blood clots, myocarditis, multisystem inflammatory disease, pneumonia, or any number of well-characterized conditions caused by Covid-19.” Instead, for some the term may invoke a chronic illness—a complex of numerous unexplained, potentially debilitating symptoms—even among those who may barely have felt sick with COVID in the acute phase. Symptoms may vary widely, and include severe fatigue, cognitive issues often described as brain fog, shortness of breath, “internal tremors,” gastrointestinal problems, palpitations, dizziness, and many other issues around the body—all typically following a mild acute respiratory infection. If the other forms of long COVID seem more easily explainable, this type is often characterized as a medical mystery.

Teasing apart which kind of long COVID a person has is important, both to advance our understanding of the illness and to best care for people. Yet lumping and splitting varieties of long COVID into categories is not easy. A given patient’s case might have features of more than one of the types that I’ve described here. Some patient advocates and researchers have tended to exclude patients in the first category—that is, survivors of protracted critical illness—from their conception of COVID long-haulers. I would argue that, insofar as we define long COVID as lasting damage and symptoms imposed by SARS-CoV-2, the full variety of severe long-term manifestations should be included in its scope. “Clinical phenotyping” studies now under way may eventually help scientists and doctors better understand the needs of different types of patients, but patients in all categories deserve better care today.

The biological mechanisms by which an acute coronavirus upper respiratory infection might lead to a bewildering range of chronic, burdensome symptoms even in the aftermath of mild infections are debated. Some scientists, for instance, believe that the virus causes an autoimmune disease akin to lupus. Meanwhile, one group of researchers has argued that even a mild respiratory infection from SARS-CoV-2 causes tiny clots to block tiny blood vessels all over the body, depriving tissues of oxygen throughout the body. Still others believe that the coronavirus causes a chronic infection, as such viruses as HIV or hepatitis C do. Meanwhile, some have emphasized the possibility of structural brain damage. While some published studies have provided support for each theory, none has been adequately validated as a central unifying thesis. Each is, however, worth continuing to explore.

A recently published investigation, conducted at the National Institutes of Health, suggests that clinicians and scientists should consider additional possibilities as potential drivers of symptoms for at least some patients. The researchers found far higher levels of physical symptoms and mental distress among subjects who had had COVID (many with long COVID) than among those who had not. Yet symptoms could not be explained by basically any test results: Researchers found effectively no substantive differences in markers of inflammation or immune activation, in objective neurocognitive testing, or in heart, lung, liver, or kidney function. And yet these patients were suffering from such symptoms as fatigue, shortness of breath, concentration and memory problems, chest pain, and more. Notably, researchers did not identify viral persistence in the bodies of patients reporting troublesome symptoms.

What this means in practice is that there are some people suffering from long COVID symptoms without evidence of structural damage to the body, autoimmunity, or chronic infection. Psychosocial strain and suffering, moreover, appears common in this population. Even pointing this out is sensitive territory—it leads some people to wrongly suggest that long COVID is less severe or concerning than those suffering from it describe, or even to question the reality of the illness. And, understandably, the invocation of psychosocial factors as potential contributing factors to suffering for some individuals may make patients feel as though they are being second-guessed. The reality, though, is that psychosocial strain is an important driver of physical symptoms and suffering—one that clinicians should treat with empathy. All suffering, after all, is ultimately produced and perceived in one place: our brain.

Severe depression, for instance, can inflict debilitating and severe physical symptoms of every sort, including crushing fatigue and withering brain fog, and is itself linked to having had COVID-19. And notably, a recent study in JAMA Psychiatry found that pre-infection psychosocial distress—e.g. depression, anxiety, or loneliness—was associated with a 30–50 percent increase in the risk of long COVID among those infected, even after adjustment for various factors. A false separation of brain and body has long plagued medicine, but it does not reflect biological reality: After all, diverse neuropsychiatric processes are associated with numerous “physical” changes, ranging from reduced blood flow to the brain to high (or low) levels of the stress hormone cortisol.

Illnesses of any cause that result in protracted time off one’s feet can also instigate (likely in conjunction with other factors) reversible cardiovascular deconditioning, wherein the blood volume contracts and the amount of blood ejected by the heart with each squeeze falls—changes that can lead to a racing heart rate or faintness when standing, as decades of studies have shown. Diverse neurological symptoms can also be produced by a glitch in the function rather than the structure of the brain—or what has been described as problems of brain “software” rather than “hardware”—resulting in conditions known as functional neurological disorders. Similar glitches, known as functional respiratory disorders, can disturb our breathing patterns or cause shortness of breath, even when our lungs are structurally normal. My point is not to speculate on some overarching hypothesis to explain all symptoms among all patients with long COVID. The whole point is that there’s unlikely to be just one. And there is still much to learn.

Research is underway to better understand this spectrum of illnesses, and their causes. But whichever diverse factors might be contributing to patients’ symptoms, we can take steps—both among clinicians and as a society—to improve lives now. Social supports can be as important as medical interventions: For those unable to work, qualification for disability assistance should not depend on a particular lab or lung-function test result. All patients with long-COVID symptoms deserve and require high-quality medical care without onerous cost barriers that may bankrupt them, which further compounds suffering. Universal healthcare is, that is to say, desperately needed to respond to this pandemic and its aftermath.

Additionally, while no specific long-COVID medications have emerged, some treatments may be helpful for improving certain symptoms regardless of the specific type of illness, such as physical rehabilitative treatments for those with shortness of breath or reduced exercise tolerance. Ensuring universal access to such specialized rehabilitative care is essential as we enter the next stage of this pandemic. So is helping patients avoid the emerging cottage industry of dodgy providers hawking unproven long-COVID therapies. Health-care professionals also need more education about the broad spectrum of COVID-19-related issues, both to improve care and reduce stigmatization of patients with all types of this illness.

Read: The pandemic after the pandemic

Doctors and scientists still have much to learn about symptoms that continue—or first turn up—months or weeks after an initial COVID infection. What’s clear today is that long COVID can be many different things. That may confound our efforts to categorize it and discuss its implications, but the sheer variety should not get in the way of care for all who are suffering.

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Adam Gaffney

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October 5, 2022