Emergence of a Deadly Coronavirus

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Autopsies of 44 people who died from COVID-19 in the first year of the pandemic showed researchers that disease-causing SARS-CoV-2 virus spread throughout the body – beyond just a respiratory disease – and remained in tissue for months. The study, from the National Institutes of Health and published in Nature, helped scientists broaden their perspectives on where SARS-CoV-2 could cause infection and persist, including the brain. The work also supported the rationale for a clinical trial evaluating the antiviral drug Paxlovid for the treatment of post-acute sequelae of COVID-19, also known as Long COVID.

Findings from the autopsies, which took place between April 2020 and March 2021, confirmed that SARS-CoV-2 primarily infected and damaged the airway and lungs. But scientists also found virus fragments (viral RNA) in 79 of 85 body locations, with some virus found up to 230 days after patient’s symptoms began. Scientists found virus in cardiovascular, lymphoid, gastrointestinal, renal, endocrine, reproductive, muscle, brain and other tissue – although none of these areas sustained significant inflammation compared to what they found in the respiratory tract. Scientists from NIH’s National Institute of Allergy and Infectious Diseases and Clinical Center led the work, closely collaborating with National Cancer Institute (NCI) pathologists, four other NIH institutes, the University of Maryland, and Maryland health care facilities in Salisbury and Towson.

China is now facing what is likely the world's largest COVID surge of the pandemic. China's public health officials say that possibly 800 million people could be infected with the coronavirus over the next few months. And several models predict that a half million people could die, possibly more.

"Recently, the deputy director of China CDC, Xiaofeng Liang, who' s a good friend of mine, was announcing through the public media that the first COVID wave may, in fact, infect around 60% of the population," says Xi Chen, who's a global health researcher at Yale University and an expert on China's health-care system.

That means about 10% of the planet's population may become infected over the course of the next 90 days.

Epidemiologist Ben Cowling agrees with this prediction. "This surge is going to come very fast, unfortunately. That's the worst thing," says Cowling, who's at the University of Hong Kong. "If it was slower, China would have time to prepare. But this is so fast. In Beijing, there's already a load of cases and [in] other major cities because it's spreading so fast.

Cowling says the virus is spreading faster in China than it's spread ever before anywhere during the pandemic. It also looks to be especially contagious in the Chinese population.

To estimate a virus's transmissibility, scientists often use a parameter called the reproductive number, or R number. Basically, the R number tells you on average how many people one sick person infects. So for instance, at the beginning of the COVID pandemic, in early 2020, the R number was about 2 or 3, Cowling says. At that time, each person spread the virus to 2 to 3 people on average. During the omicron surge here in the U.S. last winter, the R number had jumped up to about 10 or 11, studies have found.

Scientists at the China National Health Commission estimate the R number is currently a whopping 16 in China durng this surge. "This is a really high level of transmissibility," Cowling says. "That's why China couldn't keep their zero-COVID policy going. The virus is just too transmissible even for them."

On top of that, the virus appears to be spreading faster in China than omicron spread in surges elsewhere, Cowling adds. Last winter, cases doubled in the U.S. every three days or so. "Now in China, the doubling time is like hours," Cowling says. "Even if you manage to slow it down a bit, it's still going to be doubling very, very quickly. And so the hospitals are going to come under pressure possibly by the end of this month."

So why is the virus spreading so explosively there?

The reason is that the population has very little immunity to the virus because the vast majority of people have never been infected. Until recently, China has focused on massive quarantines, testing and travel restrictions to keep the virus mostly out of the country. So China prevented most people from getting infected with variants that came before omicron. But that means now nearly all 1.4 billion people are susceptible to an infection.

China currently has a few highly transmissible variants of omicron spreading across the country, including one called BF.7. But these variants in China aren't particularly unique, and the U.S. currently has the same ones or similar ones, including BF.7. In the U.S., however, none of the variants appear to be spreading as quickly as they are in China.

And what about vaccines? Will they stem the surge?

About 90% of the population over age 18 have been vaccinated with two shots of a Chinese vaccine. This course offers good protection against severe disease, Cowling says, but it doesn't protect against an infection. Furthermore, adults over age 60 need three shots of the vaccine to protect against severe disease, Cowling's research has found. Only about 50% of older people have received that third shot, NPR has reported. And that leaves about 11 million people still at high risk for hospitalization and death.

"There is great uncertainty about how many severe cases there will be," says Chen at Yale University. "Right now in Beijing we don't see many severe cases." However, the outbreak could look quite different outside major coastal cities like Beijing because rural areas have much poorer health-care systems.

"In China, there's such a large geographic disparity in terms of health-care infrastructure, ICU beds and medical professionals. Most of the hospitals with advanced treatment technologies are located in Beijing, Shanghai, Guangzhou, and all the big metropolitan areas."

Several models have predicted a large death toll for this initial surge, with at least a half million deaths, perhaps up to a million.

But that number, Chen says, depends a lot on two factors.

First off, people's behavior. If people at high risk continue to quarantine voluntarily, the death toll could be lower.

Second, how well the health-care system holds up under this pressure. "This is going to be a major test – and it's unprecedented," he says. "In my memory, I have never seen such a challenge to the Chinese health-care system."

But Cowling thinks that ultimately China will still fare much better against COVID than America has.

"China has done really well to hold back the virus for three years, and ultimately, I think, the mortality rate will still be much lower than elsewhere in the world," he says, because the country has vaccinated such a high percentage of its population overall. In other words, the death toll will likely be high, given the sheer number of people infected, but it could have been much worse without the vaccinations, he explains.

"The mortality rate in China isn't going to surpass America's mortality rate [3%] at this point," he says. "But China has a really tough winter ahead."

Americans can order four more free COVID-19 tests through the mail, starting on Thursday. It's part of the Biden administration's plan to deal with an increase in COVID cases sparked by indoor holiday gatherings.

The tests can be ordered on COVIDtests.gov and will start to ship the week of Dec. 19, a senior administration official told reporters on a conference call. The government is urging people to test themselves when they have symptoms, and before visiting with family.

It's the fourth round of free rapid tests this year. The White House had suspended the program in September and said that it would not be able to send out more kits because Congress denied requests for more funding for the program. But the administration shuffled around funds to buy more of the tests for the national stockpile, the official said.

Tests are also available at community testing sites, food banks and schools, and through Medicare. People covered by private health insurance plans can get fully reimbursed for eight tests per month.

The federal government is trying to make it easier for Americans to get vaccines, tests and COVID treatments like Paxlovid during the winter months. It is staging supplies like ventilators as well as personal protective equipment, and wants to help states set up mobile and pop-up vaccination sites.

The government has a particular focus on nursing homes and long-term care facilities, and wants to work to vaccinate residents with the latest booster shot, and offer Paxlovid to people who get the virus.

"We are a few years into this pandemic, and we are prepared for this moment," the official said.

More than 3,500 Americans have died due, at least in part, to long Covid, according to new data from the CDC. The agency’s findings underscore the potential severity of a condition that continues to impact millions but is still poorly understood and — in some cases — dismissed entirely.

The new analysis, published early Wednesday by the CDC’s Center for National Health Statistics, found that 3,544 death certificates between January 2020 and June 2022 listed Covid-19 as a cause of death in addition to citing such terms as “chronic Covid” or “long haul Covid.”

The report also found that the vast majority — or 78.5 percent — of the deaths attributed to long Covid were among white Americans. Black people accounted for just over 10 percent of long Covid deaths and Hispanic people accounted for 7.8 percent, despite those groups having higher rates of Covid-19 infection and death than white Americans over the course of the pandemic. Most of those who died were elderly Americans.

The window into long Covid mortality, while comprising less than 1 percent of Covid-19 deaths, is the latest evidence of the ongoing threat that the complex, hard-to-diagnose condition poses to Americans’ health and the stressed U.S. health care system even as Biden administration officials say Covid-19 will continue to circulate for years to come.

It also raises important questions about who can access care for a condition that impacts as many as 23 million Americans.

A death can only be attributed to long Covid if a patient is diagnosed with having it. And though a recent CDC National Center for Health Statistics survey found nearly one in five U.S. adults who say they’ve had Covid-19 also have long Covid symptoms, it remains prohibitively difficult for patients to get treatment for the condition, doctors say, due to low levels of awareness among doctors and patients, lack of funding for specialized clinics, and the time-consuming process of getting diagnosed and treated for a condition that has dozens of symptoms.

The constellation of long Covid clinics that have cropped up across the country continue to have months-long waiting lists for new patients. The relatively few patients who do get treated are overwhelmingly white and affluent enough to be able to take time off work to go to multiple appointments and spend time online finding care and support groups, doctors say.

“My patients have to work to pay their bills,” said Ramers, who treats predominantly low-income people of color. “They don’t have time to sit on the phone.”

In many other instances, patients who do seek treatment are being told that what they are experiencing after their Covid-19 infection is not a problem. “A lot of patients are being told they are just anxious,” said Alba Azola, co-director of Johns Hopkins Post-Acute Covid-19 Team, referring to the Latino patient community she often works with. While some research shows that mental health impacts how people experience disease, she said many patients are “not being properly referred or identified.”

n August, the Biden administration rolled out the National Research Action Plan on Long Covid focused on better understanding how to prevent, diagnose and treat long Covid, and named health equity as a “guiding principle” in that work. It also published a report outlining federal services available for people who have long Covid.

Sen. Tim Kaine (D-Va.), who has long Covid himself and continues to experience tingling in his nerves that started when he caught Covid in March 2020, acknowledges that there are still significant barriers to accessing long Covid care, but he is optimistic that things are moving in the right direction as more is learned about the condition.

The CARE for Long COVID Act, which Kaine sponsored, would, among other things, provide funding to the CDC to focus on better understanding the differences in access to diagnosis and treatment. He is hopeful that the $25 million in funding for this work, which was included in the latest Senate Appropriations Committee text for the end-of-year omnibus bill, will be included in the law.

Many who treat long Covid patients say lawmakers and the White House need to do more to support patients and raise awareness about the condition, particularly as deaths from it mount.

We are very under-resourced and we are completely inundated with patients,” said Janna Friedly, executive director of the University of Washington Post-Covid Rehabilitation and Recovery Clinic. “We are booked out for more than a year at this point. It’s not a good way to provide care to patients.”

She said she’d like to see the federal government provide more funding both for research and to support the few clinics that do exist.

“It’s becoming largely forgotten,” she said. “We’re seeing less attention to the lingering effects of Covid, which are still here and will be for years to come.”

Maxanne McCormick had every reason to believe she was dying of the same degenerative dementia that killed her mother. She’d been diagnosed in 2011, when she was just in her fifties: a devastating explanation for more than a decade of migraines, pain, brain fog, and fatigue so crushing that she had to quit her job as a physician’s assistant. Once, in the early days of her illness, she’d just arrived at work at a pediatric practice in Littleton, Colorado, and was struggling to clip on her badge—a dumb, mindless task she’d done a million times—when her arm froze, then started thrashing.

After her diagnosis, she enrolled in a study at the University of California at San Francisco that was gathering some of the most extensive data ever compiled on her condition. Her biannual treks west allowed clinical researchers to measure her decline. With each trip, her health worsened. She lost the ability to walk, then to speak. Eventually, needing round-the-clock care, Maxanne moved out of the home she shared with her husband and into a nursing home, where she was the youngest resident by decades. “I was basically waiting to die,” she recalled. She read a book called Final Exit help weigh the merits of medically assisted suicide.

In early 2016, she took yet another trip to UCSF. It began like any other, with aides escorting Maxanne in a wheelchair through the Denver airport and all the way to the research hospital, where researchers ran days of tests as they always had. But this time, when they gathered the team for a debrief, they shared an unexpected finding: They no longer believed she had degenerative dementia. Her MRIs were looking too stable for that. Instead, she had something called functional neurological disorder, or FND: a problem with brain processing that can result in significant suffering throughout the body without corresponding tissue damage. So-called functional symptoms are highly correlated with psychosocial distress and can be excruciating, despite evading most lab tests. Conceding that we lack the vocabulary to understand how the brain interacts with the rest of the body, most FND researchers reach for metaphor: FND is a software problem, not a hardware problem. It’s not the machinery itself that’s on the fritz, but the system that’s running it.

Maxanne told me all about FND early one morning over Zoom, her brown bob nearly washed out by sunlight pouring in through her home office window. After years of struggling to come to terms with her failing hardware, she said, she was determined to do whatever she could to reboot her software. She threw herself into the rehab exercises she was cautiously told might help retrain her brain: She focused on her reflection in the mirror, trying to direct the image to complete tasks she’d long since failed to will her own limbs to do. Maxanne’s tone—she is “Max” to her friends, blog readers, and journalists—gradually changed from deliberate and clinical to giddy as she recounted this part of the story. “The initial recovery was nothing short of miraculous,” she told me. Her speech returned right away. Within a week, she was walking again—first around the house, then around the block, then down the aisle at her youngest daughter’s wedding. “Of course, it was still difficult being around a lot of people and noise and things like that,” she said. Even today, things aren’t perfect. Her tremors escalate when she’s stressed, for example, and she schedules appointments in the morning to preempt afternoon fatigue. She demonstrated how her body still plays tricks on her: She could touch her nose easily when focused on my face on her screen, but got shaky when she paid attention to her own arm.

She started blogging about her recovery, and soon became one of the most prominent public-facing people living with FND. “This has become sort of my life’s mission,” she told me. “I care very much about helping people who are stuck on this darn pathway.”

But not everyone is happy about her work—including many of the people Maxanne had most hoped to reach, whose illnesses bear a striking resemblance to her own. Advocates of the so-called contested illnesses that number among the most controversial topics in medicine—including chronic fatigue syndrome, or ME/CFS; chronic Lyme disease; and, more recently, long Covid—fiercely reject FND as tantamount to telling patients that their suffering is all in their heads. ME/CFS activist and documentary filmmaker Jennifer Brea insists that FND is “not a diagnosis that is ready for prime time.” Other advocates quip that it’s an acronym for “fictional non-diagnosis.” They say that their illnesses are strictly physical the idea that their mental health could have anything to do with their symptoms is as offensive as dismissing HIV as anxiety.

These debates have been supercharged by the rise of long Covid, a patient-coined term invoking post-viral chronic illness that lingers after sufferers have ostensibly recovered from SARS-CoV-2. Newly minted long Covid activists have teamed up with champions of ME/CFS and related diagnoses, demanding research into biopharmaceutical interventions over psychosocial research and support. The conflict reveals stark tensions between the biomedical and biopsychosocial models of medicine that get at fundamental questions of what illness is, and what medicine can and can’t do.

Because illness is in large part socially defined, understandings of specific diagnoses have been fluid across time and space. But the most direct precursor to FND is something you’ve probably heard of: hysteria. For most people, “hysteria” evokes an abhorrent historical relic: Hippocrates’s version of “Women are crazy.” But if the diagnosis of hysteria has undeniably misogynist roots—ancient Greeks were convinced that wombs migrated throughout the body and caused all sorts of symptoms, and clinicians retained the Greek root word hystera for “uterus” when devising an amalgamated disease centuries later—hysteria as a cohesive medical category was also considered a real and miserable malady that ravaged women disproportionately but befell men as well.

And in 1964, the diagnosis was dealt a major public blow that warded off clinical interest. A British psychiatrist, Eliot Slater, examined the medical records of dozens of hysteria patients who had come through his hospital and found alternate diagnoses for each. In a now famous medical lecture, he excoriated the construct altogether: “The only thing that hysterical patients can be shown to have in common is that they are all patients…. The diagnosis of ‘hysteria’ is a disguise for ignorance and a fertile source of clinical error. It is in fact not only a delusion but a snare.”

Slater’s landmark conclusions are still lauded by those convinced that hysteria was little more than a dismissive label slapped on women sick with physical ailments. These critics offer an alternative narrative: Around the same time that Charcot was searching brains for missing lesions, reports began surfacing of patients left with lingering symptoms long after an 1889 outbreak of Russian flu. A similar pattern followed the 1918 Spanish flu. In the next decades, stories of outbreaks leaving clusters of sufferers in bed reportedly sprang up dozens of times, including in a Wisconsin convent, at an Athens midwifery institute, and among nurses at a London hospital. In 1984, in the well-to-do skiing town of Incline Village, Nevada, on Lake Tahoe, more than 100 relatively young, previously healthy patients were felled by all-encompassing fatigue. But however undeniably ill they were, clinicians struggled to pinpoint objective signs suggesting any convincing single cause.

It was the famous Lake Tahoe cluster that the Centers for Disease Control and Prevention first dubbed chronic fatigue syndrome, now more commonly known as ME/CFS (which is a compromise between the original name and “myalgic encephalomyelitis,” a term preferred by patients who argue that “chronic fatigue” doesn’t capture their condition’s severity). In the face of decades of stigma—comedian Ricky Gervais infamously mocked ME/CFS in 2007 as “the one where ‘don’t feel like going to work today’”—advocates and a committed core of researchers nonetheless forged a body of knowledge about a disease that they estimate receives the lowest funding, relative to its burden, from the National Institutes of Health. One survey showed that more than 70 percent of patient respondents reported an infection had triggered their illness, and the diagnosis includes symptoms such as extreme fatigue, sleep troubles, and pain. Its defining diagnostic criterion is post-exertional malaise, or a significant depletion of energy following physical or mental exertion. For the past few years, the CDC website has offered a disclaimer in its coverage of ME/CFS: “ME/CFS is a biological illness, not a psychologic disorder. Patients with ME/CFS are neither malingering nor seeking secondary gain. These patients have multiple pathophysiological changes that affect multiple systems.”

In other words, stress could exacerbate FND, and someone with FND could overfocus on symptoms and essentially turn up their volume, requiring brain processing for actions that should be automatic. As Carson put it to me, the term “functional neurological disorder” should be reserved for neurological symptoms like weakness, seizures, memory loss, or cognitive issues. “Functional symptoms” and “functional disorders” are largely used interchangeably about other parts of the body. Irritable bowel syndrome, for example, is widely theorized to be a functional disorder. Meanwhile, conditions like depression and anxiety frequently include symptoms most people would describe as physical. It’s even possible to have functional and nonfunctional symptoms at the same time. “We wonder why people get confused!” Carson quipped.

In the early days of the Covid-19 pandemic, the contours of a by now familiar story began to reveal themselves. After being infected with the novel coronavirus, some people weren’t recovering as quickly as expected. In mid-April 2020, journalist Fiona Lowenstein published an op-ed in TheNew York Times called “WE NEED TO TALK ABOUT WHAT CORONAVIRUS RECOVERIES LOOK LIKE.” Lowenstein had founded a survivor support group for people whose symptoms still hadn’t resolved after many weeks. Soon, an infectious-disease specialist at the Liverpool School of Tropical Medicine, Paul Garner, wrote a series of blog posts for the British Medical Journal about the harrowing aftermath of his Covid-19 illness: “For 7 weeks I have been through a roller coaster of ill health, extreme emotions, and utter exhaustion,” one headline read. In subsequent posts, he described intense brain fog, tinnitus, and a bad relapse after hitting an aerobics class: “I was more exhausted than ever and could not get out of bed for three days,” he wrote, a spot-on description of “post-exertional malaise,” although he didn’t know that at the time. In June 2020, Lowenstein and Garner were both key sources in Pulitzer Prize winner Ed Yong’s first Atlantic feature about what patients in online support groups soon dubbed “long Covid.”

More stories from Yong and many others followed, and the picture they painted was frightening. People who had relatively mild initial bouts of Covid-19 were in awful shape weeks, months, and even a year or more later. One early feature described sufferers experiencing “extreme fatigue, bulging veins, excessive bruising, an erratic heartbeat, short-term memory loss, gynecological problems, sensitivity to light and sounds, and brain fog.” Others developed new allergies and extreme itchiness, bouts of blindness and paralysis, or joint pain and hair loss. Plenty of patients were falling ill after apparently asymptomatic cases of Covid-19. After the slow-to-recover started gathering online, one survey identified 200 symptoms associated with the emerging malady.

Almost immediately, ME/CFS advocates recognized what was going on: Long Covid, they believed, was simply the latest wave of their own disease, which often followed viral infection. Thanks to the sheer scale of the coronavirus pandemic, its existence was more undeniable than ever. As Jaime Seltzer of the advocacy group MEAction put it to WebMD, if the portion of people who end up with long-lasting illness is “similar to what has been seen for other pathogens, then we’re looking at a mass disabling event.” Subsequent studies have suggested that around half of people with persistent symptoms after Covid-19 fit the diagnostic criteria of ME/CFS. Seeing common cause, existing advocacy networks allied with newly minted long Covid advocates. MEAction has reportedly contacted hundreds of journalists and clinicians since the start of the pandemic to emphasize the connection between ME/CFS and long Covid.

Almost three years into the SARS-CoV-2 pandemic, their arguments have become the consensus of experts around the world, shaping public and professional understandings of long Covid as a complex, chronic, organic disease neglected by science. Meanwhile, so much research piled up suggesting physiological dysfunction linked to long Covid that some people began to wonder if the overall toll of long Covid exceeded that of the acute disease. Studies have linked long Covid to immune dysfunction, chronic inflammation, tiny blood clots that depleted the brain of oxygen, and even the Epstein-Barr virus, which strong evidence suggests may cause multiple sclerosis.

Most recently, a study led by Yale immunologist Akiko Iwasaki and Mount Sinai physical therapist David Putrino offered further evidence of measurable physiological abnormalities in long Covid patients: reduced T cells, for example, and lower levels of cortisol. “We hope our study will be informative to others working in the field,” Iwasaki reflected on Twitter upon the release of the preprint. “We also hope that these data will help those who are still skeptical understand that long COVID is real, and it has a biological basis.”

But Long Covid was never exactly as cut and dried as some quarters made it out to be. If advocates have seen the past few years as an overdue reckoning for medicine’s eternal indifference toward women and the diseases that disproportionately befall them, others have seen it as something else: a dramatic illustration of suffering driven by psychosocial distress, and how poorly medicine is equipped to handle it.

The latter case goes something like this: A chronic illness that appeared to be triggered by viral infection could just as easily have been triggered by the trauma of the pandemic itself. That long Covid, ME/CFS, and related diagnoses disproportionately target women perhaps stems from the fact that, in a patriarchal world, women face more adversity and have less control over their lives.

The eye-popping range of issues linked to long Covid raises questions about whether all are ascribable to viral infection, particularly since two of the most widely reported symptoms—fatigue and brain fog—are also commonly associated with stress, depression, anxiety, and functional disorders like FND. Since 2019, rates of people reportedly experiencing depression and anxiety have quadrupled, according to some estimates; loneliness and isolation spiked as well. One recent study found all of these things to be highly correlated with long Covid. Cell-level and hormonal findings along the lines of those in the Putrino and Iwasaki study have also been observed in chronic pain, post-traumatic stress disorder, and depression, but often don’t seem to correlate with symptoms, and it’s unclear what any of it means clinically, or whether there’s any causal relationship. Finally, an NIH-sponsored longitudinal study on long Covid—the most thorough and detailed analysis of the condition yet produced—found no tissue damage in long Covid patients, no evidence of viral persistence, and no abnormalities in any organ function relative to controls. “We are finding little to no abnormalities,” lead author Dr. Michael Sneller told NPR before the study’s publication. “Echocardiogram, pulmonary function tests, X-rays, brain MRIs. You name it. Laboratory markers of organ dysfunction. We’re not seeing any of that … and precious little evidence of immune activation.… I’m running out of tests to do, basically.” One association his final paper did find, however, was an association between long Covid and anxiety disorder.

Furthermore, the association between infection and acute illness with long Covid appears tenuous. A detailed early cohort study conducted by patients themselves found that, while the availability of PCR testing lagged early in the pandemic, the majority of participants eventually underwent antibody testing—but over two-thirds of those participants tested negative, suggesting that even after accounting for false negatives, and for the possibility of antibodies never materializing or fading over time, at least some portion of them never had Covid-19 to begin with. Other long Covid research raises questions, too: Some widely cited studies used no control groups, made inappropriate comparisons (for example, contrasting debilitated long Covid patients with self-reportedly healthy people instead of, say, people with extreme depression), or were published in borderline predatory pay-to-play journals with dodgy peer review processes.

Meanwhile, there is evidence hinting that some symptoms chalked up to long Covid may well be functional. Alan Carson, one of the leading neuropsychiatrists on functional symptoms, told me that he’s seen plenty of FND and other functional disorders at long Covid clinics in Edinburgh. Many studies are missing detailed clinical assessments by experienced physicians, he told me, relying instead on brief sessions with intake nurses and searches for novel biomarkers. In one case, he reexamined long Covid patients who had undergone much shorter evaluations in a previous study, and found context other investigators had missed. He determined that one long Covid patient who was unable to walk had functional paralysis that was likely triggered by his traumatic hospitalization early in the pandemic: “He’d been awake and conscious much of the time he’d spent in the ICU,” Carson told me. “And he’d been exposed to a lot of people dying in pretty horrible ways, thinking, ‘Oh, I’m next.’” For Carson, the idea that the etiology of this man’s symptoms would render him less worthy of care or sympathy than someone whose symptoms are caused by physical tissue damage is troubling. Some people are willing to “feel sorry for the sufferers,” he said, only “if we find a traditional pathogenic mechanism … and that, to me, seems a fundamentally flawed point.”

Mark Hallett, the NIH doctor, has also seen functional symptoms within both long Covid and ME/CFS cohorts. “Some patients will have an organic etiology for their post-Covid syndrome, other patients will have a functional etiology,” he told me. “We don’t want to say that any diagnosis is bad. Functional disorder is not voluntary. People are not doing it to themselves. That’s just the way the brain is reacting to their particular situation.”

The head encases the only organ capable of experiencing any illness at all—and whose function is irrevocably affected by love, poverty, violence, housing, hopelessness. So in that sense, perhaps long Covid is all in your head. Just like everything else.

Does that mean that long Covid is “all in their head”? In one way, no—of course it doesn’t. The symptoms are real, and patients’ testimony about them is sacrosanct. They are not confused, faking, or unreliable. They’re sick. But in another way, the head encases the only organ capable of experiencing any illness at all—and whose function is irrevocably affected by love, poverty, angst, violence, terror, geography, housing, monotony, hopelessness, and so on and so on. There’s no feeling or interpreting anything outside of your brain. So yes, perhaps long Covid is all in your head. Just like everything else.

For all their disagreements, proponents of the biomedical and biopsychosocial models of long Covid share considerable common ground. The Covid-19 pandemic has driven widespread debility, whether a result of distress or the virus itself, compounded in either case by political abandonment and public health failures. Both camps emphasize that patients are really suffering, and that it isn’t their fault. Where they diverge is on questions of treatment.

By the mid-2000s, Michael Sharpe had spent years treating the kinds of patients he’d first come across at the infectious-disease clinic at Oxford: people with persistent, chronic symptoms that were sapping the brightness from their lives. He couldn’t make patients’ lives perfect, but he could help them improve. “It’s basically just what we used to call rehabilitation,” he told me. “It’s helping people accept the situation they’re in, to give them some hope for the future and help them gradually move forward.”

In 2005, Sharpe began recruiting patients to participate in the largest-scale clinical trial ever run on ME/CFS to see if his restorative methods could help those patients, too. The PACE trial study protocol, which was designed in collaboration with a British ME/CFS patient charity, strove to determine whether graded exercise therapy, or GET, and cognitive behavioral therapy could improve outcomes. In 2011, Sharpe and his co-authors published their answer: GET and CBT did moderately improve the health of ME/CFS patients. Few study participants made a miraculous turnaround, and some didn’t respond much at all, but there was an undeniable if modest boost overall. That made GET and CBT the only clinically validated treatment for ME/CFS.

Four years later, journalist David Tuller wrote a 15,000-word critique of the PACE trial, which he called “bogus and really terrible research.” Dozens of researchers, clinicians, and advocates joined him in his criticism. They wrote an open letter to The Lancet calling for an independent investigation, circulated a petition demanding a retraction, and condemned the trial in other outlets.* An extended court battle forced Sharpe and his co-researchers to hand over their data, which detractors reanalyzed and claimed undermined the PACE conclusions. The psychologist David Marks, editor of the Journal of Health Psychology summarized his objections to what PACE represented: “Gaslighting has been applied to the entire ME/CFS community by misapplication and misuse of the biopsychosocial model.”

Considering PACE’s ultimately rather mundane finding, the tenacity of the response is surprising. “It’s quite hard to think of any chronic illness where some psychologically informed rehabilitation doesn’t help,” Sharpe told me. Ditto for carefully graded exercise. Today, despite the blowback, Sharpe stands by his research. “It’s been hammered probably like no trial in history ever has. It’s been debated in the U.K. House of Parliament three times. It’s still there—no one has killed it.” Neither The Lancet nor the Medical Research Council UK disavowed it. More importantly, he said, “some people’s lives will be damaged because they won’t have rehabilitation when they could have, and that’s terrible.”

What he’s saying is hardly a stretch. Advocates have successfully gotten GET and CBT withdrawn from official ME/CFS treatment guidelines in the United States and the U.K. and have also objected to it as a treatment for long Covid. The Atlantic’s Ed Yong—the most respected reporter in the world on long Covid—labeled PACE “now discredited,” and warned that anyone with post-exertional malaise who pushes themselves to exercise could get “permanently worse”—a claim that isn’t evidence-based, and that would make the condition suspiciously unique in the annals of medical knowledge. MEAction is running a PSA campaign geared toward warding viewers away from the treatments validated by PACE. Its website contains links to anecdotes about patients who say they had to go to bed or use wheelchairs after short walks.

Even worse, hucksters and fringe quacks have reportedly begun administering all sorts of unproven treatments, and affixing long Covid patients with dubious diagnoses requiring unsubstantiated tests and treatments.

For Maxanne McCormick, the former physician’s assistant who recovered from the worst of FND with methods resembling CBT and GET, the risky treatments patients get sucked into are disturbing. But she understands how such sick people could feel abandoned by medicine—after all, she once felt that way, too.

When she started getting sick, before her diagnosis of degenerative dementia, she was diagnosed with “conversion disorder,” the Freudian diagnostic label that succeeded hysteria and preceded FND. Back then, even fewer clinicians understood how to handle functional symptoms, and the standard of care was basically to shrug and send the patient home, or shunt them off to therapy. Maxanne felt alienated by the diagnosis, and the doctors weren’t helpful—plenty, of course, still aren’t. “It was really horrible to go for help and be treated with contempt,” she recalled. “It just cuts at your soul. And I didn’t ever want that to happen again.” Maxanne did try therapy, and even appreciated it—it helped her begin to process an abusive childhood. But she couldn’t see how it was connected with her migraines, fatigue, or tremors.

So Maxanne shied away from further treatment, and her health gradually got worse. It was another 15 years before medicine finally began to get it right.

It’s tempting to see Maxanne’s story as yet another illustration of a point often made about long Covid: As public health professionals Steven Phillips and Michelle Williams put it in The New England Journal of Medicine last year, “Our medical system has a long history of minimizing women’s symptoms and dismissing or misdiagnosing their conditions as psychological.”

Perhaps, but the truth is more complicated than that. In a profit-driven system, if some symptoms get minimized, others are maximized. Thanks to overdiagnosis and overtreatment, 25,000 women in the United States undergo unnecessary breast cancer treatment each year, per one recent estimate. It’s widely acknowledged that most C-sections are not medically necessary.

It’s tiresome how often statements like “dismissing women’s conditions as psychological” go unchallenged—as if so-called psychological illnesses are frivolous or fake rather than some of the most persistent and irrevocable drivers of human suffering.

Over the last two centuries of the history of medicine, there have been a few breakthroughs that transformed how we think about our lives.

For those who see contested illnesses through a biomedical lens, this history is inspiring, and the need for scientific research into cures is a no-brainer. But the model doesn’t work for every type of suffering. There is unlikely ever to be a penicillin for long Covid or ME/CFS. Indeed, even as we’ve churned out pills and shots that target specific pathogens and render the scourges of yesteryear practically irrelevant, we’ve never gotten very good at treating some of our most common chronic symptoms, such as brain fog, fatigue, and pain. Drugs can zero in on a pathogen, but they aren’t so good at targeting the biopsychosocial factors that shape our well-being.

Several years into a global pandemic, it’s appalling how often medicine struggles to identify—let alone appropriately treat—functional disorders or symptoms provoked by psychosocial distress. When faced with such patients, the most odious doctors will drop them down a chute into crankland, where they’ll be subject to a dubious or even dangerous barrage of tests, tweaks, and experimental procedures rarely billable to insurance. Many others will do what they did to Maxanne back in the early 2000s—pathologize them and send them away.

Zachary Grin, a physical therapist specializing in FND, told me that, unlike conventional rehab with a more specific focus—say, leg strengthening exercises after a leg injury—functional symptoms require more systemic work to reset the connection between brain and body. He asks patients to count backward by three during exercises, or practice going up stairs backward, to reset their autopilot. That is more or less what Max and her care team have tried to do, through rehab drills, stress management, habit building, and practicing various motions in the mirror. Paul Garner—the infectious-disease doctor in the U.K. who wrote some of the earliest first-person pieces about long Covid—recovered in a similar way. Both say that embracing a biopsychosocial framework has been key to their recovery, and they have concerns about how the dominant media narrative is affecting patients. “I had to stop the Facebook groups, get away from talking about my symptoms, and try to put them into context,” Garner told me.

People like Maxanne and Paul were fortunate to get better from the worst points in their lives. So many people don’t. What both of them had—and what every ill person deserves, regardless of the cause of their symptoms—is support. They were loved and helped by family members, able to survive without working during their illness, and enjoyed secure housing and access to good health care—all the tools they needed to thrive.

Once we finally recognize how dramatically illness is driven by psychosocial distress, we can get to work engineering less of it through politics. We can provide better social and disability support for sick people, give them time to convalesce, redistribute resources so that no one is balancing their health on the edge of their last nerve. We can fund robust childcare, family leave, and early childhood education to alleviate the systemic strain that burdens women and disproportionately makes them sick. We can fight for universal health care built on a comprehensive primary care system, so that doctors and patients develop meaningful clinical relationships over time, and patients can discuss their concerns and manage symptoms over time in appointments less encumbered by revenue maximization.

In the meantime, we can do more to educate clinicians and the public that patients like Maxanne deserved dignity and empathy all along.

ASPartOfMe wrote that "More than 3,500 Americans have died due, at least in part, to long Covid,"

But over 1,090,000 Americans have died from COVID.

You also provided a link that said:
China is now facing what is likely the world's largest COVID surge of the pandemic. China's public health officials say that possibly 800 million people could be infected with the coronavirus over the next few months. And several models predict that a half million people could die, possibly more

China has for the past few years claimed to have suffered minimal damage due to COVID.
Officially they claim a total of 5,235 deaths for 334,119 infections. So has China been hiding the true numbers for the past 2 years?
(Worldometer)

Funeral homes across China's COVID-hit capital Beijing, a city of 22 million, scrambled on Saturday to keep up with calls for funeral and cremation services as workers and drivers testing positive for the novel coronavirus called in sick.

Moving away from endless testing, lockdowns and heavy travel restrictions, China is realigning with a world that has largely reopened to live with COVID.

China has told its population of 1.4 billion to nurse their mild symptoms at home unless symptoms become severe, as cities across China brace for their first waves of infections.

In Beijing, which has yet to report any COVID deaths since the policies changed on Dec. 7, sick workers have hit the staffing of services from restaurants and courier firms to its roughly one dozen funeral parlours.

"We've fewer cars and workers now," a staffer at Miyun Funeral Home told Reuters, adding that there was a mounting backlog of demand for cremation services.

"We've many workers who tested positive."

It was not immediately clear if the struggle to meet the increased demand for cremation was due to a rise in COVID-related deaths.

At Huairou Funeral Home, a body had to wait for three days before it could be cremated, a staffer said.

China's health authority last reported COVID deaths on Dec. 3. The Chinese capital last reported a fatality on Nov. 23.

Yet respected Chinese news outlet Caixin reported on Friday that two veteran state media journalists had died after contracting COVID-19 in Beijing, among the first known deaths since China dismantled most of its zero-COVID policies. And on Saturday, Caixin reported a 23-year-old medical student in Sichuan died of COVID on Dec. 14.

Still, the National Health Commission on Saturday reported no change to its official COVID death tally of 5,235.

China's abrupt lifting of its ultra-strict policies could cause over a million deaths through 2023, according to the U.S.-based Institute of Health Metrics and Evaluation (IHME).

Had those policies been lifted earlier, say on Jan. 3 this year, 250,000 people in China would have died, prominent Chinese epidemiologist Wu Zunyou said on Saturday.

As of Dec. 5, the proportion of seriously or critically ill COVID patients had dropped to 0.18% of reported cases, Wu said, from 3.32% last year and 16.47% in 2020.

This shows China's fatality rate is gradually falling, he said, without elaborating.

It was unclear if the proportion of severely ill has changed since Dec. 5. Regular PCR testing and mandatory reporting of cases was scrapped on Dec. 7.

"There're long queues of hearses here, and it's hard to say when there'll be available slots," said a staffer at Dongjiao Funeral Home.

"Normal deaths," the staffer said, when asked if the deaths were COVID-related.

The lack of reported COVID deaths for the past 10 days have stirred debate on social media over data disclosure, fuelled also by a dearth of statistics over hospitalisations and the number of seriously ill.

"Why can't these statistics be found? What's going on? Did they not tally them or they just aren't announcing them?" one netizen on Chinese social media asked.

China stopped publishing asymptomatic cases from Wednesday, citing a lack of PCR testing among people with no symptoms that was making it difficult to accurately tally the total count.

Official figures have become an unreliable guide as less testing is being done across the country following the easing of zero-COVID policies.

In Shanghai, more than 1,000 km (620 miles) south of Beijing, local education authorities on Saturday told most schools to hold classes online starting on Monday, to cope with worsening COVID infections across China.

Downtown Beijing was largely deserted this week as people seemingly stayed home to avoid infections.

There are shortages of some medicines as residents stockpile them along with other supplies. Hospitals face a rise in patients and staff catching the virus. And there were social media reports of people panic-buying lemons and peaches after spurious social media trends suggested falsely that they were effective treatments.

It’s difficult to know exactly how bad things are.

Anecdotally, many people in Beijing describe a widespread outbreak.

“My family is OK, but more than half of my colleagues have Covid right now,” Yueying Wang, 22, a university student who interns at a tech company, told NBC News.

James Zimmermann, a lawyer, posted on Twitter earlier this week that 90% of his office was sickened.

This is not a spike, this is a tsunami,” said Jin Dong-Yan, a professor at the University of Hong Kong who studies viral diseases.

However, the dizzying policy shift has not been met by scenes of liberation, with many residents seemingly deciding to lock themselves down in an apparent bid to shelter from the waves of uncertainty and infections that have coincided with the reopening.

On Wangfujing, a popular pedestrian shopping street in the capital, NBC News witnessed more security guards and police than pedestrians wandering around earlier this week. Tai Taikoo Li, another upscale area, has been virtually empty all week even though restrictions were lifted. And the large, usually thronging Shunyi New World Shopping Mall was nearly empty of customers.

Dr. Mike Ryan, the emergencies director at the World Health Organization, told a news briefing Wednesday that he believes Chinese officials saw that lockdowns “were not stopping the disease” and “decided strategically that was not the best option anymore.”

But now that wave is underway, many experts are worried that the reopening — and the risk of lots of people becoming infected all at once — has the potential to overwhelm China’s health care system.

The main worry is that millions of Chinese people — almost 1 in 3 over the age of 60, according to official figures — haven’t had a third booster shot, leaving them more exposed to serious illness.

The government has recently ramped up its bid to vaccinate reluctant older people.

And because China has avoided large waves so far, it lacks the immunity through infection that many other countries have obtained as a side product of their massive and deadly waves.

“I’m really worried about how the hospitals and intensive care units are going to hold up with such a large number of infections in a short space of time,” said Ben Cowling, the chair of epidemiology at Hong Kong University. “Most likely the majority of the population will be infected within a fairly short space of time because the only thing that’s going to stop this virus is when everybody’s had it.”

Anticipating a potential shortage of available staff in hospitals as the virus spreads, the Global Times newspaper, the Chinese Communist Party’s bullish mouthpiece, openly suggested that some may be asked to continue working despite being sick to avoid the risk of patients going untreated.

The abrupt lifting of restrictions could result in over a million deaths through 2023, according to new projections from the U.S.-based Institute of Health Metrics and Evaluation, which has been relied on by governments and companies throughout the pandemic.

China’s health care system tends to be overreliant on hospitals, with people often seeking care there even for less severe illnesses. Cold and flu medicines are now difficult to come by in pharmacies, according to The Associated Press. The National Health Commission said on Friday that it was building up stocks of essential drugs as well as ventilators.

BF.7, has recently been identified as the main variant spreading in Beijing, and is contributing to a wider surge of COVID infections in China.

BF.7, short for BA.5.2.1.7, is a sub-lineage of the Omicron variant BA.5.

Reports from China indicate BF.7 has the strongest infection ability out of the Omicron subvariants in the country, being quicker to transmit than other variants, having a shorter incubation period, and with greater capacity to infect people who have had a previous COVID infection, or been vaccinated, or both.

To put this into context, BF.7 is believed to have an R0, or basic reproduction number, of 10 to 18.6. This means an infected person will transmit the virus to an average of 10 to 18.6 other people. Research has shown Omicron has an average R0 of 5.08.

The high transmission rate of BF.7, taken with the risk of hidden spread due to the many asymptomatic carriers, is understood to be causing significant difficulty in controlling the epidemic in China.

The symptoms of an infection with BF.7 are similar to those associated with other Omicron subvariants, primarily upper respiratory symptoms. Patients may have a fever, cough, sore throat, runny nose and fatigue, among other symptoms. A minority of people can also experience gastrointestinal symptoms like vomiting and diarrhoea.

BF.7 may well cause more serious illness in people with weaker immune systems.

BF.7 carries a specific mutation, R346T, in the spike protein of SARS-CoV-2 (a protein on the surface of the virus that allows it to attach to and infect our cells). This mutation, which we also see in BF.7's "parent" variant BA.5, has been linked with enhancing the capacity of the virus to escape neutralizing antibodies generated by vaccines or previous infection.

A recent study examined the neutralization of BF.7 in sera (a component of blood that should contain antibodies) from triple-vaccinated healthcare workers, as well as patients infected during the Omicron BA.1 and BA.5 waves of the pandemic. BF.7 was resistant to neutralization, driven partly by the R346T mutation.

BF.7 has been detected in several other countries around the world including India, the U.S., the UK and several European countries such as Belgium, Germany, France and Denmark.

Despite BF.7's immune-evasive characteristics, and worrying signs about its growth in China, the variant seems to be remaining fairly steady elsewhere. For example, in the US it was estimated to account for 5.7% of infections up to Dec. 10, down from 6.6% the week prior.

While the UK Health Security Agency identified BF.7 as one of the most concerning variants in terms of both growth and neutralization data in a technical briefing published in October (it accounted for over 7% of cases at that time), the most recent briefing says BF.7 has been de-escalated due to reduced incidence and low growth rates in the UK.

We don't know exactly why the situation looks different in China. BF.7's high R0 might be due in part to a low level of immunity in the Chinese population from previous infection, and possibly vaccination too. We should, of course, be cautious about the data from China as it's based on reports, not peer-reviewed

Men and women who worked out at least 30 minutes most days were about four times more likely to survive covid-19 than inactive people, according to an eye-opening study of exercise and coronavirus outcomes among almost 200,000 adults in Southern California.

The study found that exercise, in almost any amount, reduced people’s risks for a severe coronavirus infection. Even people who worked out for as little as 11 minutes a week — yes, a week — experienced lower risks of hospitalization or death from covid than those who moved about less.

“It turns out exercise is even more powerful than we thought” at protecting people from severe covid, said Robert Sallis, a clinical professor at Kaiser Permanente Bernard J. Tyson School of Medicine in Los Angeles and senior author of the new study.

The findings add to mounting evidence that any amount of exercise helps lower the ferocity of coronavirus infections, a message with particular relevance now, as holiday travel and gatherings ramp up and covid cases continue to rise.

Science already offers copious support for the idea that regular, moderate exercise increases our immune response and generally helps us avoid respiratory infections or recover more rapidly if we do catch a bug.

o, for the new study, which was published this month in the American Journal of Preventive Medicine, Sallis and his colleagues again turned to anonymized records about patients of Kaiser Permanente. Since 2009, that health-care system has included exercise as one of the vital signs health-care workers check during each patient visit, meaning they ask patients how many days per week they exercise, typically by walking, and for how many minutes.

The researchers now drew the records for 194,191 Kaiser patients who had been diagnosed with covid between Jan. 1, 2020, and May 31, 2021, and seen a doctor at least three times in recent years, so their records held multiple mentions of their exercise habits.

Averaging that information, the researchers divided people into five groups, based on how much they moved and whether their habits had changed over the years. The least-active group consisted of those who regularly exercised for fewer than 10 minutes a week. The most active consistently worked out at least 150 minutes per week, which is the amount of exercise recommended by federal health agencies.

In-between were groups whose exercise habits had changed from one medical appointment to the next, but generally kept them moving for more than 10 minutes but fewer than an hour a week, and others who regularly worked out for at least an hour weekly, but fewer than 150 minutes.

The patients, in other words, represented most average people’s exercise routines.

Next, the researchers checked everyone’s medical records for conditions known to contribute to serious covid outcomes, including obesity, high blood pressure and heart disease.

Finally, they cross-checked data about hospitalization or death of covid and people’s exercise habits.

The correlations proved to be “very strong, across-the-board,” Sallis said. The more someone exercised, he said, the less likely he or she was to be hospitalized or die after developing covid.

The differences were most extreme between those who almost never exercised and those who worked out at least 150 minutes per week. The never-exercisers were 391 percent more likely to die after developing covid than the active men and women — whether they had obesity, high blood pressure or existing heart disease.

But even among those who worked out less often, managing perhaps 10 or 15 minutes a week, that exercise translated into reduced odds of serious covid.

The data in the study was collected before widespread coronavirus vaccines were available, but Sallis thinks the results would be similar among vaccinated people.

The study has limitations, though. People self-reported their exercise; it wasn’t objectively tracked. The researchers also looked at improving covid outcomes, not preventing coronavirus infections. And, while they found strong links between being active and avoiding serious covid illness, other factors may be at play. People who exercise might have higher incomes, for instance, or other lifestyle aspects that influence their health, although the researchers tried to account for those issues.

About 38 percent of passengers on one flight into Milan’s Malpensa Airport tested positive for COVID-19, as did about 52 percent of those on a second flight, according to local officials in Italy’s Lombardy region.

It’s unlikely that a dangerous new Covid-19 variant is spreading in China, said Dr. Chris Murray, Seattle-based director of a health research center at the University of Washington.

His comments Friday on CNBC’s “Squawk Box Asia” come as U.S. health officials warned this week about the chance of a new Covid variant emerging in China’s nationwide outbreak — and how Beijing’s lack of transparency could delay detection of public health risks.

Murray, director of the Institute for Health Metrics and Evaluation, pointed out there were likely billions of omicron infections worldwide this year, but no new Covid variant has emerged, only subvariants of omicron.

“That’s why I would put the risk as quite low that there is a dangerous new variant in China,” Murray said. He noted that “some very special characteristics” would be needed for a new variant to emerge and replace omicron.

Unlike much of the world, China’s Covid wave this month is affecting a population of 1.4 billion people who are mostly getting infected for the first time. Only domestically made vaccines are widely available to locals.

The U.S., Japan and a few other countries this week subsequently announced new Covid testing requirements for travelers from China.

Murray said that an outright travel ban, if proposed, “would not make sense,” and that he “would not put in testing requirements.”

“The argument that’s being made is, we need more transparency about what’s happening in China,” Murray said.

“The earliest sign of some new variant is actually going to be a change in the hospitalization or the death rate associated with Covid, and not just lots of infections, because we know omicron does that,” he said.

China’s National Health Commission said Sunday it would stop releasing daily information on Covid infections and deaths. However, the Chinese Center for Disease Control and Prevention has maintained daily reports — which, along with hospital discharges, only show thousands of new Covid infections a day and a handful of deaths. Covid testing is no longer mandatory in China.

Releases on China’s disease control center website show its director, Shen Hongbing, held online meetings this month with his U.S. counterpart and the head of the U.K. Health Security Agency.

A study published in Nature Medicine in November also found that getting infected by Covid-19 more than once increases the risk of organ failure and death.