by Sanjay Gupta
It’s important to continue to build connections with other people for your emotional well-being and general health, but not with people who make you feel unsafe. Research has shown that pointing fingers, blaming, or shaming anyone for their behaviors (or lack thereof in the case of vaccine refusal) is not helpful. Remember: Share; don’t shame is my motto. If your friends are hesitant to get vaccinated, share your great experience about how freeing it is to be so protected from COVID. The majority of people who are hesitant to get vaccinated are not stupid or selfish. They simply want more information and reassurances from people they trust—their friends, mentors, doctors, colleagues, and family members. That means you and me.
Find a New Work-Life Balance
I think I speak for millions of people when I say never has my work-life balance been more disrupted than during this pandemic. We got sent to our rooms for over a year. We actually began to miss long commutes that allowed us some peace and quiet and time to reflect (I missed long flights to destinations for reporting). The pandemic blurred the lines—and passage of time—between work and play. One woman put it perfectly: “I feel less like I’m working from home and more like I’m living at work.” I won’t even mention what it’s been like for people raising kids. But work and life should not compete, and it helps to think of work as merely part of life, and we get to choose how it appears. With many people returning to traditional offices full- or part-time in a hybrid model, it’s key to strike a new balance. Some tips:
• Make a mental commitment to boundaries. Have a designated workspace and time, choosing your work hours (if possible) to take place when you’re most creative and productive. Do not respond immediately to messages outside those working hours. For me, this means organizing my day like a surgeon—being precise, methodical, and procedural. If your office uses chat apps or Slack, change your status to “off work” or “do not disturb” when you’re done with working hours. Be willing to say, “I have a commitment this evening but can look at that tomorrow.” As a boss once said to me, “No can be a full sentence in these situations.” You don’t have to have plans to want some time for yourself outside work. Communicate transparently with your colleagues about your work hours and schedule. We can be more flexible with where we work, and that’s a good thing. If you find yourself anxious and socially awkward as you ease back into old work settings, be patient with yourself. A little social anxiety after more than a year spent mostly at a safe distance from others is totally normal.
• Set realistic expectations on a daily and weekly basis for yourself at work and at home, even if they occur in the same place.
• Establish a nonnegotiable twenty-minute transition period in between work and play during which you maintain a ritual (e.g., meditating, reading, journaling, walking around the block) that calms and invigorates you.
• Reset the division of labor. When the late Supreme Court justice’s son misbehaved, school officials often called Ruth Bader Ginsberg. She reminded the school that her son had two parents and asked it to alternate between them. Clearly, that was several decades ago, but the lesson remains just as relevant today. Women have suffered disproportionately during the pandemic, with many leaving the workforce entirely or downshifting careers. Couples need to work as a team and accept that some days will be better than others.
Learn to Live with Germs
We cringe when we touch a dirty ATM keypad on the street or accidentally inhale someone’s sneeze nearby. Nothing looks the same anymore. Even a public restroom feels like a hazard zone (indeed, as MIT researchers have shown, “toilet plume,” an airborne dispersal of microscopic particles created by the flush of a toilet, is a real phenomenon and, in some cases, a valid public health concern).6 It’s not easy to transmit many pathogenic germs, including COVID, on surfaces, but our perceptions of what’s dirty or germy have definitely changed. Between the copious bottles of hand sanitizer, disinfecting sprays, and antimicrobial products, you’d think we’re cleansing the world and sterilizing ourselves. But we are awash in microbes whether we like it or not, and as you have now learned, many of our microbial comrades are beneficial to human health. My brief description of the human microbiome is one example of how friendly germs are part of who we are. They can be our best friends. We could never rid ourselves of all germs and should not want to do so. At some point, as COVID infection rates abate with community immunity, we’ll need to dial back our antimicrobial efforts lest we harm our immune systems paradoxically by depriving them of their continual education.
It was the British epidemiologist David Strachan who in 1989 used the alliterative term hygiene hypothesis, making the case that exposure to infections during childhood provides a good defense against allergies in later life.7 He proposed that a lower incidence of infection in early childhood could be an explanation for the twentieth-century uptick in allergic diseases and asthma. In the British Medical Journal (now just called the BMJ), Strachan published his early findings that children in larger households had fewer instances of hay fever because they are exposed to germs by older siblings. This led to further research showing that a lack of early-childhood exposure to microbes can increase an individual’s susceptibility to disease. It established the theory that a rising incidence of chronic allergic diseases such as hay fever (allergic rhinitis), eczema, and asthma may be an inevitable price to be paid for freedom from the burden of killer infectious diseases. The hygiene hypothesis, also called the microbial hypothesis or old friends hypothesis to avoid the overemphasis on cleanliness, has evolved over the past thirty-some years with plenty of critics debating its finer points, but there’s scientific consensus that certain exposures promote health and being too clean can backfire. The hypothesis has also been extended to explain conditions as diverse as food allergies, autoimmune diseases (e.g., type 1 diabetes and multiple sclerosis), inflammatory bowel disease, some cancers, and even Alzheimer’s disease.8
The concept is analogous to what happens when you build muscle mass and strength through weight training. By gradually increasing the weight of objects you lift over time, you teach and prime your muscles to work and more easily lift those heavy things. According to immunologists I interviewed, the same idea is true for the immune system. To fight off an infection, which is a “weight” of sorts, the immune system must train and learn by fighting off contaminants found in everyday life. Systems that aren’t exposed to contaminants have trouble with the heavy lifting of fighting off infections. We must still be hygienic during periods such as flu season, but it should not become an obsession. Remember, we need to tap-dance our way through our existence on the planet, not isolate ourselves from it. Once we’ve reached community immunity with COVID, we should end our hygiene zealotry and start lifting our weights again.
When Dr. B. Brett Finlay, a professor in the department of microbiology and immunology at the University of British Columbia, teaches about the microbiome, he points out that our bodies contain at least as many bacterial cells as human cells and that before the pandemic, only one of the top ten causes of death in America, influenza, was attributable to an infectious disease that someone could “catch.”9 Nearly all the rest, such as heart disease, cancer, brain disease and stroke, diabetes, and obesity, are associated with poor microbiome health or dysfunction. Dr. Finlay’s 2021 paper raised the alarm about the microbial fallout that may follow in the pandemic’s wake. “You can’t change your genes, but you can change your microbes,” he says. “They’re our friends.”
Special Note for Long-Haulers
Of all the mysterious features of COVID, its long-term effects in some people puzzle even the most brilliant doctors and scientists. For most people, COVID is a disease that involves a few weeks of discomfort, or, for the sick or elderly, it is one that can lead to hospitalization or death. But for others, it’s a disease that waxes and wanes over time with no end in sight, even after a relatively mild or asymptomatic case in the initial stage. It becomes an ongoing hardship for both the individual w
ith the illness and the entire family around that person. And it demands an inclusive, collective approach as a family unit to help a loved one through the challenges.
Research suggests that 50 to 80 percent of people who recover from COVID experience at least some lingering aftereffects three months after infection.10 Although estimates vary, at least 10 percent (and upwards of 30 percent) of people who get COVID could become long-haulers indefinitely whose prognosis is uncertain, which can be scary. In the United States, that amounts to nearly 10 million people left with prolonged symptoms. This condition is so debilitating that it has delayed or derailed careers, kept people from going back to work, and made everyday living and completion of the simplest tasks excruciating.
We need to put our arms around these people and take care of them, learning from their experience so we can formulate the best treatments and cures. Despite the staggering numbers, there are no clear diagnoses, no standard care, and no national guidelines for how these patients should be treated. Once we can better define long-haul COVID, my hope is we can help patients manage and treat their disease like any other chronic condition through the right medicine and healthy lifestyle. The medical community is rapidly creating standardized definitions and guidelines of care. Despite some similarities among long-haulers—often women in their thirties, forties, and fifties—we don’t have any diagnostic criteria. Images of the lungs or heart can’t help us identify post-COVID illness. That COVID can become chronic partly explains why patients who have had it bear a 60 percent higher risk of death between one and six months after getting sick than those who never had the infection. And patients who have had COVID also show a 20 percent greater chance of needing more medical care and medication over the six months after their diagnosis. Chronic conditions breed other chronic conditions, and the body can become vulnerable to a spectrum of illness and disorder.
Dr. Francis Collins, director of the National Institutes of Health (Dr. Fauci’s boss), has announced a major commitment to understanding long-haul COVID with an initiative worth $1.15 billion over four years to fund investigations of the conditions associated with it. And those conditions are extensive, often occurring in waves: extreme fatigue, fevers, muscle aches, heart palpitations and irregular heart rhythms, changes in blood pressure, shortness of breath; headache, confusion, dizziness, loss of hearing, tinnitus, and inability to concentrate (“brain fog”); diarrhea, nausea, vomiting, and loss of taste and smell or phantom smells and tastes; mouth sores, twitchy muscles, eye infections, hair loss, and skin conditions; as well as psychiatric and mood conditions such as anxiety, paranoia, delirium, and depression. Long-haul neurological symptoms like anxiety disorders and depression seem to be distinct from neurological complications found in the acute phase, such as a stroke or seizures. And while we don’t know yet if COVID can have very long-term consequences, such as a recovered twentysomething living with an increased risk for dementia or Alzheimer’s disease later in life, the current thinking suggests COVID is primarily an inflammatory vascular disease with downstream effects. In other words, while it may not cause brain disease in and of itself, patients may still have similar symptoms.
“I think of COVID as a medical illness with multiple related sequelae that can fast-forward or trigger cognitive decline and brain disease, but so can so many other things,” says Dr. Richard Isaacson, a neurologist at New York–Presbyterian/Weill Cornell Medical Center and founder of its Alzheimer’s Prevention Clinic. The vast majority of his patients go back to their baseline cognitive status after recovering from COVID. Whether the virus directly attacks the brain remains debated, as studies fail to detect the COVID virus in the brains of people who died of it. But we do know that during the acute phase of infection, there may be inflammation in the brain, an autoimmune reaction, and an impairment of the autonomic nervous system’s ability to regulate certain bodily processes. There may also be vascular changes that underlie some of the neurological conditions doctors see in patients. Research scientists are beginning to document two big driving forces in the long-haul phenomenon: organ and blood vessel damage caused by the infection and an immune overreaction, or the virus lingering in the body to perpetuate problems.
This last idea, that COVID can remain hidden somewhere in the body, would put it in the same bucket as other infections that can lie dormant and strike later on such as chicken pox and shingles. Research has also revealed that COVID may cause changes to an infected person’s genes, influencing their behavior. To be clear, the virus is not changing your DNA but it can impact how genes express themselves dynamically, which can impact the inflammatory response in the body. Research scientists at Texas Tech University Health Sciences Center have found that exposure to the infamous COVID spike protein alone was enough to change baseline gene expression in the airway cells of infected patients, suggesting that the first COVID symptoms someone develops may initially result from the spike protein interacting with the cells directly, even more than the infection itself.11
In many ways, that brings us back to the beginning of this part of the book and the concept of epigenetics. External forces act on our genetic code every day. These signals have the power to change how our genes behave and how our DNA is turned into messages and building blocks for our body—which means you have the ability to alter, for better or worse, the activity of your DNA. By definition, epigenetics is the study of how your behaviors and environment can cause changes that affect the way your genes work. Unlike genetic changes, epigenetic changes are reversible and do not change your DNA sequence, but they can change how your body reads a DNA sequence.12 Put another way, epigenetic changes affect gene expression to turn genes “on” and “off.” Since your environment and behaviors, such as diet and exercise, can result in epigenetic changes, it is easy to see the connection between your genes and your behaviors and environment. And it’s how we get to decide which genetic switches we want to turn on or off.
Now, how does an infection like COVID become an epigenetic force? Although we all know that our environment and our lifestyle choices, such as what we eat and how we exercise, play a significant role in our health, we often don’t think about the subtler forms of “environment” that have an impact on us, such as an infection. An individual’s response to COVID and whether he or she goes on to develop a long-haul illness are likely the result of a complex interplay of genetic, epigenetic, and environmental factors. I believe we will find patterns in the data from long-haulers and be able to better predict who is more likely to have a prolonged illness.
Long-haul recovery programs are appearing throughout the country and at places like Mount Sinai Hospital in New York where a post-COVID clinic has been established. When Diana Berrent launched Survivor Corps in spring 2020 to help mobilize and collect data and research tools for patients and doctors alike, she didn’t expect the following to grow so fast.13 But it’s a testament to the problem and the ever-expanding need for answers and treatments. Berrent was among the first people to contract COVID in New York back in March 2020. She went on to have long-haul symptoms for months after testing negative for the virus, with those symptoms ranging from headaches and stomach issues to glaucoma, increasing her risk for blindness. Her preteen son also contracted the virus and still had symptoms nine months later.
“It’s like we’ve lost limbs that we now must find a way to grow back,” one survivor explained to me. That analogy is useful, because there’s no such thing as growing back an arm or a leg (if only that were possible!). If your leg has been amputated, your new normal likely involves learning how to walk again with a prosthetic device. It’s probably not helpful to yearn for life before the amputation and regret all that you can no longer do. Such obsessive thinking about the past can hinder progress in the recovery. The same goes for COVID survivors, many of whom do not fit the stereotypical profile of people we’d expect to have a bad outcome with COVID. They are young. They are fit. They are high school sports stars, adults in their prime with no previous health prob
lems or preexisting conditions, professional athletes, special operations military personnel, and doctors themselves. They cannot make sense of their body’s roller-coaster reaction to COVID. Although women seem to be more at risk for long-haul COVID, we cannot dismiss the outliers to that pattern who are part of this conversation and whose experience will add to our knowledge and library of COVID medicine.
My advice to anyone suffering from long-haul COVID is to find one of these post-COVID clinics near you that bring together specialists across the board—pulmonary, cardiology, and neurology. Make it a “family affair” in medicine and at home. This takes a multidisciplinary group approach to cover the panoply of syndromes. Survivor Corps (SurvivorCorps.com) is a great gateway for resources. It is worth noting that many long-haulers have found relief through vaccination, which is great news and a clue to what is causing the symptoms to persist in the first place. For everyone else, it also provides another reason to get vaccinated and stay on top of possible booster shots in the future.