As the roll out of vaccination and the staged end of lockdown appear to be coalescing into a shift in planning and return to work, there are numerous questions and challenges to be answered and resolved.
THE POST-ACUTE COVID-19 SYNDROME (LONG COVID)
First and foremost, is that emerging data suggests that the effects of infection with SARS-CoV-2 are far reaching, extending beyond those with severe acute disease. Specifically, the presence of persistent symptoms after apparent resolution from COVID-19 have frequently been reported throughout the pandemic by individuals variously labelled as “long-haulers and long Covid sufferers”. Incredibly, some evidence is indicating that between as many as 10-30% of survivors of Covid-19 say they still experience symptoms. Just reviewing the implications of this sheer number implies that a review of the mechanisms and treatments is urgently required as this is likely to be a significant drain on health care resource. In the UK in February 2021 a small financial sum of £18.5million has been awarded for 4 research studies.
Yet there remains considerable uncertainty about its treatment and resolution. It is highly likely that the role of specialists as employed in our current model of care, will be less effective in finding the resolution than those using a multidisciplinary or functional medicine approach. Inevitably, although there will be common pathways, the specialist level of involvement and understanding will vary from patient to patient, meaning a personalised approach rather than a standardised one will be needed.
Many experiencing the effects of post-acute COVID syndrome will epitomise the kind whom the medical system frequently fails, by contesting the reality of their illness, sending them from specialist to specialist, loading them up with medicines and opinions without getting to the root cause. Yet, the answer is that it is a single system disease, the immune system, which impacts diverse organs at different times and in differing levels of severity.
FEMALE RISKS
This seems to be reflected in age and gender differences, for while men are at increased risk of severe infection, women seem to be more affected by long COVID and this may reflect their different or changing hormone status. For example the ACE2 receptor that SARS-CoV-2 uses to infect the body is present not only on the surface of respiratory cells, but also on the cells of many organs that produce hormones, including the thyroid, adrenal gland and ovaries.
Preliminary data (yet to be published) shared with scientific advisers (in SAGE) suggests that women under 50 are five times as likely as men under 50 to report a new disability, six times as likely to experience greater breathlessness, and twice as likely to feel more fatigued up to 11 months after leaving hospital. Its likely a similar spread is also reflected in those who were not admitted, as there appears to be no consistency between severity of the acute phase and development of post acute symptoms – but fatigue and being female of working age are common and linked components.
The notion that the immune system’s response to a pathogen could be what does much of the damage to our bodies is not new to practitioners using the functional medicine approach to care. This relative new paradigm for more conventional reductionist trained clinicians holds that disease is a multipronged phenomenon, an interaction among pathogens (whether viruses or bacteria), the immune system, and “environment,” a term that covers one’s microbiome or one’s exposure to such things as toxic chemicals and trauma. Included in this is the pre-priming of risk of serious adverse acute and long haul consequences, where existing autoantibody production is already in existence as explored in Oct 2020 in the Journal Science.
Various patterns of symptoms are emerging including heart scale related vascular output challenges similar to postural orthostatic tachycardia syndrome (POTS), environmental sensitivity, respiratory challenges, brain fog and others with classic chronic fatigue like presentations of easy exhaustion and poor recovery with various stages of symptom development. At the vanguard of an emerging personalised medicine, the new view of post viral illness takes into account the variety of individual immune responses to infections, which, we now know, are influenced by the social, gender, nutritional and genetic determinants of health, among them the stresses of poverty and systemic racism.
WOMEN AND WORK
If there is any reason for hope in the growing epidemic of long COVID, it is that some academic medical research teams are taking these patients seriously and starting to tailor treatment to them. Yet we know that medicine’s history with hard-to-identify chronic illnesses, particularly those that mainly affect women, has not been a good one. For decades now, marginalised patients who have felt mysteriously unwell, with ME/CFS, with post-treatment Lyme disease syndrome, with Ehlers-Danlos syndrome, and more have been lumped together into activist groups to try to legitimise their experiences.
Globally, the pandemic has killed more men but disadvantaged more women’s careers and it seems leaves them at greater risk of lingering consequences. Women are more likely to work part-time and freelance and are often self-employed, exactly the type of jobs that have been furloughed or cut or have missed out on government financial support. They are more likely to have care responsibilities. Because men tend to earn more, if in a heterosexual couple one partner’s career must be prioritised, it is usually theirs. In the UK, mothers are 23% more likely than fathers to have lost their jobs, according to the Institute for Fiscal Studies. Demonstrating that we are not all in this together, women have had to bear a greater level of personal, mental and physical health, family and work-related costs.
In health care delivery, especially nutrition, the field is dominated by women, many of whom are now under exponential strain to hold it all together and get through the ongoing challenges to their function, health and futures.
SOME SIMPLE, EFFECTIVE, HEALTH AND WORK SOLUTIONS
One intervention that is low risk and potentially helpful in the recovery of long Covid, and useful for enhanced breath control (energy generation)is the use of respiratory retraining. The Stasis program is deceptively simple and strikingly low-tech: It involves inhaling and exhaling through your nose in prescribed counts in the morning and at night. Developed at Mt Sinai Hospital in the States, I anticipate it will not be long before a similar proposal will evolve in the UK. Start by inhaling through the nose for four counts and exhaling for six in the morning, and in the evening, inhaling for four, holding for four, and exhaling for four as with other patterns seems to reset respiration and reduce symptoms.
Energy generation has the production of ATP at its core. Without the approximately daily production and recycling of ATP equivalent to body weight, the capacity to function will quickly decline. Mitochondria, are the primary source of ATP and are organelles with a double membrane that serves as a cell’s primary source of energy production and contributes to homeostasis, cell proliferation, cell death, and synthesis of amino acids, lipids, and nucleotides. In the event of an infection, mitochondria also contribute to immunity by engaging the interferon system, altering their structure, and inducing programmed cell death. Loss of mitochondria functionality is linked to Covid-19 infection and the related damage, may be a key component of post acute Covid-19 recovery. Prof Nicholson and Michael Ash have published a number of narrative reviews on the role of NT Factor in the restoration of mitochondrial function and the related recovery from fatigue.
CONCLUSION
It is likely that the preponderance of post-acute infection symptoms will drive further research and clinical interventions for other long term nonspecific fatigue dominated illnesses. The additional consequences of women being the gender that experiences multiple adverse events, should motivate you to identify the role of a functional medicine approach to clinical care. It is likely that as more mechanisms are uncovered, lifestyle and nutrition will offer more opportunities for recovery than medicines, an opportunity to reverse the compression of work loss and create a new and exciting delivery of safe effective health care that recognises the interplay of multiple systems simultaneously.
