“I think they (government agencies) are itching to pretend that COVID is over and that long COVID does not exist,” says Ziyad Al-Aly, director of the Clinical Epidemiology Center at Veterans Affairs St. Louis Health Care System and lead author of the review. “It is much more pleasant to pretend as if emergency department visits and hospitalizations haven’t been rising sharply this summer.”

In a Nature Medicine review this week, Al-Aly and several other top researchers lay out a difficult truth: Long COVID has already affected an estimated 400 million people worldwide, a number the authors say is likely conservative, at an economic cost of about $1 trillion annually—equivalent to 1% of the global economy.

Moreover, the risk of a person being hit with long COVID rises with repeated infections of the virus itself, and recent COVID activity has experts watching closely. As review co-author Eric Topol noted in a recent blog post, the current COVID incursion is ramping up quickly, with one modeler estimating 900,000 new infections per day in the U.S. alone.

“The new significant wave,” Topol said via X. “It’s hard to believe the we are well into our fifth year of this virus and not taking the requisite steps to gain control.”

The new significant wave. It's hard to believe the we're well into our 5th year of this virus and not taking the requisite steps to gain control.
Including updates on the new boosters and #LongCovid.
In Ground Truths (link found in my profile) pic.twitter.com/Et1M7MKhbV

— Eric Topol (@EricTopol) August 5, 2024

The virus is evolving incessantly. Multiple COVID subvariants, collectively nicknamed FLiRT, are powerfully present in the U.S., and reports from California indicate that some patients are complaining of throat pain so strong it feels like they’re “swallowing razors or broken glass,” according to the Los Angeles Times. Topol, meanwhile, says the Sato Lab in Japan has characterized one of the newest COVID strains, KP.3.1.1, in a preprint as having “the most immune evasion and infectivity of any of the variants” derived from previous powerful iterations of the JN.1 strain, which was prominent last winter.

Although the Centers for Disease Control and Prevention says that severe outcomes and deaths from COVID have decreased substantially overall from the pandemic’s early days, wastewater data shows viral activity is “high’ nationally and COVID-19 infections are growing or likely growing in 35 states. More COVID infections mean more cases of long COVID. And long COVID is already exacting an enormous toll on both the people and economies of the world.

Those are words you aren’t hearing from many government bodies. But, the researchers say, the evidence tells the story.

“Despite the dire impact of long COVID on individuals and society, I fear that many are still unaware of the danger,” says Akiko Iwasaki, professor of immunology at Yale School of Medicine and co-lead investigator of the university’s COVID-19 Recovery Study. “There is an urgent need to provide proper diagnosis and treatment for people living with long COVID.”

The authors lay out a number of preventive policy recommendations, including increased use of masking, improved ventilation systems and a vaccination program that pairs COVID shots with season flu shots to extend their reach to improve uptake. But there’s a genuine question as to whether enough folks are paying close attention for any of this to matter.

As the authors point out, a survey found that as of last August, one-third of American adults still hadn’t even heard of long COVID. In reality, long COVID was identified and defined in the first full year of the pandemic, 2020, and it has been increasing its case count ever since.

This form of COVID is particularly perilous because, for many people, its symptoms may last years (or a lifetime) and their effects may trigger all sorts of associated problems and costs. Long COVID “affects nearly every organ system,” the review notes, including the cardiovascular, immune, gastrointestinal and reproductive systems. While more than 200 symptoms have been identified, common symptoms include memory problems, difficulty concentrating, fatigue, heart palpitations, chronic cough, shortness or breath and recurring headaches.

Chillingly, most people who develop long COVID did not have particularly vicious cases of the virus initially. That’s in part because so many more people experience a mild form of COVID rather than a severe one. (Across most studies, long COVID risk does increase with the severity of the initial infection.) And each time people become reinfected with the virus, they’re at risk of developing long COVID, even if they didn’t experience it previously.

The authors note that studies on recovery from long COVID are “sparse and inconsistent.” But those that have closely evaluated individual manifestations of the virus have found recovery rates to be fairly low at one year, and only 7% to 10% fully recovered after two years. For millions and millions of people, the debilitating effects of long COVID are just that.

The economic toll is its own story. A Census Bureau Household Pulse Survey in 2022 found that between 2 million and 4 million working-age Americans were out of work because they were sidelined with the effects of long COVID. Meanwhile 20% of people with long COVID surveyed by the United Kingdom’s Trades Union Congress said they were not working. Another 16% were working reduced schedules.

The $1 trillion estimated annual global economic hit involves Organization for Economic Cooperation and Development (OECD) countries due to “reductions in quality of life and labor force participation,” the Nature Medicine review says. And that price tag does not factor in the direct costs of healthcare, another likely category of deep financial fissure.

Al-Aly and his co-authors are pleading for governments, especially U.S. health agencies, to dramatically upgrade their levels of activity to investigate long COVID, learn more about its mechanisms and pathways, and develop vaccines that better block infection. They’re also pushing for large-scale platform trials to test multiple drugs simultaneously, so we can quickly learn what works and what doesn’t.

They have an ally in Congress. U.S. Sen. Bernie Sanders recently introduced the Long COVID Research Moonshot Act, a bill that would guarantee $1 billion per year for a decade to the National Institutes of Health “to support long COVID research, the urgent pursuit of treatments, and the expansion of care for patients across the country.”

Sanders’ news release announcing the act puts the long COVID count in the U.S. at 22 million, including a million children. Among other things, the bill would require NIH to establish a long COVID database and a grant process to speed up clinical trials, and to make any subsequent treatments “reasonably priced” so that every patient could receive it.

“The legislation that we have introduced finally recognizes that long COVID is a public health emergency,” Sanders said. “Congress must act now to ensure treatments are developed and made available for Americans struggling with long COVID.”

If it accomplishes nothing else, Sanders’ proposal may help lift the veil on long COVID in the country and around the world. It’s a topic that has been largely pushed into the shadows, as governmental agencies—and official policy—tried to construct a reality in which COVID in general was just no longer a significant issue.

That was never the case, and it’s certainly not the case now. “The reality is otherwise,” Al-Aly says. As the virus mutates into new strains and continues to affect millions, the long tail of COVID is once again forcing itself to center stage.

For more on COVID-19:

• New COVID vaccines are here. What to know about 2024–25 shots as summer surge continues
• The summer COVID surge has arrived. Here’s the latest on symptoms and treatment
• FLiRT COVID variants: What to know about symptoms and spread
• COVID can damage your vision, even if you didn’t have symptoms. Experts say to watch for these signs
• COVID can cause new health problems years after infection