Long COVID: A public health concern needing urgent attention

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Dr. Farrukh A. Chishtie

The ambulances quietened, the wards unclogged, the nightly dashboards slipped from the news. Yet in homes, schools, shops, and clinics across Pakistan, the illness of long COVID had refused to leave. A bus conductor climbs one flight and his heart skitters. A teacher loses the thread halfway through a lesson. A university student reads the same page three times and retains nothing.

Post-COVID-19 condition, widely called Long COVID, names a pattern that begins within three months of infection and lingers for months beyond, with fatigue, breathlessness, sleep disturbance, pain, and cognitive dysfunction that do not yield to a simple prescription. It is multi-system, variable, and stubborn. Most importantly for public health, it disables participation in ordinary life.

Occupational security is the right lens for this moment. Security is not only a matter of borders or budgets, it is the reliable ability to take part in daily occupations with dignity, learning, earning, caregiving, and belonging. By that measure Pakistan is not yet in recovery. If a nurse avoids the ward stairs, if a mechanic cannot tolerate heat and solvents for a full shift, if a student cannot get through double mathematics without a crash, the medium of daily life has failed. The test of our response is simple. Do people get their lives back, or are they left to disappear into disbelief, normal tests, and unpaid rest. Recovery is not the absence of symptoms on paper; it is the return of safe participation.

How large is the burden, and who is missing from the count

Long COVID is difficult to count precisely because many of those affected never return to hospital and many were never admitted in the first place. Even so, a coherent picture emerges. Pakistan’s official line lists capture only a fraction of total infections, and community surveys suggest a far larger denominator. A cautious application of international prevalence estimates implies a cohort measured in the hundreds of thousands, very plausibly more than one million people, living with long-tail disability. These are not only the previously hospitalised, they are also teachers, drivers, clerks, vendors, and students who had mild infections and never imagined a second chapter.

Under-counting is not a neutral error. It is an inequity engine. Rural women who hold households together, outdoor and informal workers who cannot afford a day off, and students outside urban hubs without access to neurocognitive assessment, are least likely to be recognised and most likely to be harmed. An occupational-security approach demands that we design for those least able to step away from their roles. That means naming the condition clearly in Urdu and English, coding it in routine health information systems, and publishing simple, trusted dashboards that show where symptoms cluster, where services exist, and how quickly people reach help. Numbers that are visible become budgets that move. If we do not count it, we will not fund it. If we do not fund it, families will pay for it with years.

What it looks like in bodies, homes, and workplaces

Clinicians now recognise repeating constellations of Long COVID. Exertional intolerance turns ordinary tasks into triggers for crashes that last days. Dyspnoea and chest tightness keep people from stairs and heat. Autonomic instability brings dizziness, palpitations, and temperature sensitivity on standing. Cognitive injury, the so-called brain fog, steals attention, slows processing, and blurs working memory. Children are not spared, and their school performance narrows along with their play. None of this is exotic, yet the experience is frequently met with suspicion. Normal blood tests do not invalidate disabling fatigue; a clear X-ray does not cancel breathlessness on stairs.

If authenticity and accuracy are to become public values, then primary care must align behaviour with evidence. Recognise the syndrome. Screen for red flags. Teach pacing and energy management. Refer those with complex multi-system involvement to multidisciplinary teams. Translate symptoms into accommodations that preserve everyday occupations. A vendor may need shorter shifts and a cooler stall; a teacher may need quieter rooms and scheduled breaks; a student may need reduced load and extended time. Participation is the clinical outcome. Believe the patient, map the occupation, and build the accommodation.

Where the system breaks, and how to bend it back toward participation

Pakistan entered the pandemic with underfunded primary care, uneven access beyond major cities, thin rehabilitation capacity, and fragile mental health coverage. Long COVID amplifies each seam. Basic health units rarely screen for autonomic dysfunction or cognitive complaints. District hospitals seldom run multidisciplinary day clinics where internal medicine, respiratory and cardiology sit with neurology, psychiatry or psychology, and, critically, occupational therapy and physical therapy. Neuropsychology is concentrated in a few cities, often priced beyond reach. With no surveillance module in the routine information system there is no line of sight for planners. With no simple algorithm at the front line, clinicians improvise. With no task-shifting to Lady Health Workers, rural families are left without a map a short walk from home.

A credible correction is within reach. Issue an evidence based approach for Basic Health Units (BHUs) and tehsil hospitals, in Urdu and English, that sets out recognition, basic screening, orthostatic vitals, short cognitive and mood screens, pacing education, and follow up. Stand up district day clinics that include occupational therapy and physical therapy by design, not as an afterthought. Use tele-rehabilitation from urban hubs to support Lady Health Workers who can deliver breath retraining and energy conservation at home. Add a Long COVID module to the national health information system so that facilities can code cases consistently and follow outcomes that matter, time to first rehabilitation visit, return to school, and return to work. Publish monthly dashboards that let the public see progress and gaps. The point is not to admire the problem. The point is to restore the conditions for daily life.

The bill that starts in a kitchen and ends in the national accounts

A trillion dollars at the global level is hard to grasp until it lands in a kitchen. Long COVID reduces participation and productivity, lengthens absences, and pushes people out of jobs long after the emergency phase has ended. In an economy with a large informal sector the same physiology produces sharper social costs. No work means no wage. One parent’s fatigue becomes a child’s dropout risk. One worker’s breathlessness becomes household debt. Small employers feel the shock immediately, through churn, overtime, and missed orders. Larger institutions feel it in absenteeism that never quite returns to baseline.

Pakistan can choose a different accounting. If we measure success as restored participation rather than normal test results, then the correct financial instruments are those that underwrite function, service packages at district level, tele-rehabilitation that reaches villages, employer guidance that standardises graded return, and school accommodations that keep students on track. These are modest line items compared with the long-run losses in human capital that follow untreated cognitive and autonomic sequelae. Pay for rehabilitation today or pay for lost human capital for a generation.

Prevention that works today, vaccination, reinfection control, and clean air

Prevention has two sturdy pillars. The first is immunological. Vaccination reduces the odds of Long COVID, and boosters matter where coverage has thinned. Pakistan has already shown that it can bring vaccines to where life happens. The second pillar is environmental and behavioural. Clean indoor air standards for crowded workplaces, masks during surges or in poorly ventilated spaces, and paid sick leave that discourages infectious attendance reduce reinfections that compound risk. None of these measures is exotic, and each protects the only outcome that truly counts, keeping people able to participate.

Clarity prevents suffering. The national message should be simple and repeated. Long COVID is real. It has a practical map. Pacing is treatment, not weakness. Help lives in primary care, in district day clinics, in community rehabilitation delivered by Lady Health Workers, and in employer and school accommodations that are written down rather than improvised. When authorities speak plainly, stigma recedes and care seeking rises. When they hedge, households pay the price in confusion and delay.

Care pathways that Pakistan can stand up within the year

Start in the system we have. Place a concise algorithm in every BHU and tehsil hospital. Recognise the syndrome, screen for red flags, check orthostatic vitals, use short cognitive and mood screens, teach pacing and energy management, and arrange follow up. Refer complex cases for multidisciplinary assessment. At district level, run day clinics anchored by internal medicine, respiratory medicine, and cardiology, with scheduled input from neurology and psychiatry or psychology, and with occupational therapy and physical therapy at the core. The clinical task is to map essential occupations, identify environmental and temporal accommodations, and design graded activity that respects post-exertional symptoms rather than provoking relapse.

For households far from cities, build a community-based rehabilitation layer delivered by Lady Health Workers and supported by tele-rehabilitation from urban hubs. Use simple home tools, breath retraining, spacing of tasks, balance and strength routines, and carer education. Pair clinical care with workplace and school playbooks. Graded return is engineering, not indulgence. Shorter initial hours, protected rest breaks, quiet spaces, reduced cognitive load, and review cadences linked to symptoms keep people in their roles without breaking them. The outcome to watch is not discharge from clinic, it is stability in school and work over months.

Investment in research and innovation, Pakistan’s opportunity to lead for South Asia

Research is not a luxury in a constrained system; it is the engine that turns limited rupees into maximum participation. Pakistan needs longitudinal cohorts that follow people for one to three years, with deliberate oversampling where our risk profile is unique. Diabetes, hypertension, and cardiovascular disease are common and may shape prognosis. Gender and age likely modify neurocognitive outcomes. Pakistan needs neuropsychological assessment protocols that work outside major cities, along with cognitive rehabilitation models adapted to Urdu and regional languages. Pakistan needs trials of community-based rehabilitation and tele-rehabilitation that test task-shifting to Lady Health Workers and evaluate low-cost breath retraining and energy conservation bundles that can be delivered at scale. Pakistan needs health-economics studies that tie specific clinical and occupational interventions to the outcomes that matter most, retained students and retained workers.

To fund this agenda, establish a Long COVID Research and Innovation Window within a national platform that can blend domestic funds with international support. Set a three-year envelope with milestones that matter to families rather than only to journals, a registry module live in the national information system, algorithms printed and distributed to primary care, rehabilitation pilots enrolling in each province, quarterly reports on return to school and return to work. Partner with universities for laboratory and imaging sub-studies but keep the centre of gravity in community and district settings where most people live. Align calls with global roadmaps, but make the questions our own, fitted to our demography, our comorbidities, our work patterns, and our languages. Research that does not reach the Basic Health Unit (BHU) is a missed investment. Put discovery where people live.

Closing, a Pakistan plan judged by participation, not by press releases

Here is the summary, without euphemism: name the condition in public and in code, so people stop blaming themselves and planners can see what is happening. Build a simple pathway in primary care that respects what people feel and what the evidence shows and make sure every clinician can find it. Stand up district day clinics with occupational therapy and physical therapy at the table, because the goal is restored function, not only normal laboratory values. Extend reach through Lady Health Workers and tele-rehabilitation, so a family in Tharparkar or Chitral gets the same map as a family in Lahore. Tell employers and schools how to keep people in their roles without breaking them and set that expectation in policy. Track the whole effort with a registry and a dashboard that show, quarter by quarter, how fast people are getting help and how often they are keeping jobs and staying in school. Publish the spending so that the public can trust the numbers.

Pakistan learned during the emergency that time matters. The country that built testing centres overnight can build rehabilitation routes in daylight. The health workers who held the line in 2020 can learn the new maps in 2025. The public that wore masks for strangers can learn, again, that we survive best when we make one another’s participation possible. Long COVID has stolen breath, energy, memory, and confidence. Our answer should give them back, first in weeks and months, then for the years and pandemics ahead.

What is Long COVID?

The short answer

Long COVID is a set of health problems that begin after a COVID-19 infection and then last for weeks or months. Symptoms often start within three months of the infection and last at least two months. There is no single test. Doctors make the diagnosis from history, current symptoms, and by ruling out other causes.

What it feels like

People describe deep tiredness that does not lift with rest. Many feel short of breath on stairs or in heat. Some have chest tightness or a racing heartbeat when they stand. Thinking can feel foggy. Memory is unreliable. Sleep is broken. Joints ache. Headaches return. Symptoms can be steady or can flare after physical or mental effort. Children and teenagers can be affected as well.

Why this matters for daily life

Long COVID interrupts the basic occupations that keep life moving. Students struggle to focus in class. Vendors shorten shifts and lose income. Nurses avoid stairs between wards. Parents cannot carry toddlers without palpitations. When ordinary tasks are unsafe or exhausting, occupational security is broken. Recovery means getting safe participation back.

Who can get it

Anyone who has had COVID-19 can develop Long COVID. It can follow mild or severe illness. Older adults, people with chronic conditions such as diabetes or heart disease, and those with repeated infections may be at higher risk. Vaccination appears to lower the chance of Long COVID but does not reduce it to zero.

How doctors assess it

A clinician will ask about the original infection, current symptoms, and how those symptoms affect work, school, and care at home. They may check oxygen levels, heart rate and blood pressure lying and standing, breathing tests, and simple screens for mood and memory. Many tests can be normal even when daily function is limited. That does not mean the problem is not real.

When to seek urgent care

Go to urgent care if you have chest pain that does not settle, fainting, new weakness on one side, severe shortness of breath at rest, bluish lips or nails, confusion, or dehydration from vomiting or diarrhoea. These are red flags and need immediate attention.

What helps right now

Pacing and energy management. Plan your day around what you can do without a crash. Break tasks into smaller steps. Rest before you feel spent. Breath and body. Gentle breath training, graded position changes, and light strengthening can help. Increase activity slowly and stop if symptoms surge. Sleep and stress. Keep a regular sleep time, reduce late screen use, and treat pain or anxiety that worsens symptoms. Health conditions. Control blood pressure, blood sugar, asthma, or reflux. Treat what can be treated while you work on the rest. Vaccination and reinfection control. Stay up to date with vaccines. Improve indoor air and ventilation. Wear a good mask in crowded indoor spaces during surges.

School and work plans that protect function

Students can succeed with a reduced course load, extended time for tests, quiet rooms for study, and flexible deadlines. Workers can stay employed with shorter shifts at first, protected rest breaks, cooler or less physically demanding posts, and a plan to increase hours only when symptoms are stable for several weeks. The guiding rule is simple. Increase slowly. Do not push through crashes. Protect tomorrow.

What families and carers can do

Help track symptoms and energy in a simple diary. Share the pattern with the clinician and the school or employer. Protect rest time. Spread heavy tasks over the week. Keep hope realistic. Progress often comes in small steps.

Myths and facts

Myth: Long COVID is only anxiety.

Fact: It is a real, multi-system condition that affects breath, heart rate, thinking, sleep, and more. Mental health support helps, but it is not the whole story.

Myth: Normal tests mean you are fine.

Fact: Many people have normal scans and blood work and still have disabling symptoms. Function is the measure that matters.

Myth: Exercise fixes it fast.

Fact: Some improve with careful activity. Many get worse if they increase too quickly. Pacing first. Progress later.

Myth: Children do not get Long COVID.

Fact: They can. Schools can help with lighter loads and a quiet place to rest.

Long COVID: Technical brief for clinicians

Definition and nosology. Post-COVID-19 condition (Long COVID) is a heterogeneous, multi-system sequela of SARS-CoV-2 infection in which symptoms begin within approximately 3 months of the acute illness, persist for at least 2 months, and are not better explained by another diagnosis. It may follow asymptomatic, mild, moderate, or severe acute disease. The syndrome exhibits fluctuating trajectories and symptom clusters rather than a single phenotype.

Epidemiology and risk profile. Prevalence varies by study design, population, variant period, and ascertainment method. Signal persists across age groups and across ambulatory and hospital cohorts. Reported risk modifiers include female sex in several cohorts, middle age, higher acute viral burden, lack of prior vaccination, cardiometabolic comorbidity, asthma, autoimmune disease, and repeated infections. Children and adolescents are affected with generally lower point estimates than adults but clinically relevant functional impact in a subset.

Clinical phenotypes

Recurrent clusters include:

• Exertional intolerance with post-exertional symptom exacerbation characterized by delayed flares 24 to 72 hours after physical or cognitive load.

• Respiratory and chest symptoms such as dyspnoea, chest pressure, cough, and reduced exercise tolerance.

• Autonomic dysfunction with orthostatic intolerance, tachycardia, presyncope, and heat or postural sensitivity consistent with POTS-spectrum presentations.

• Neurocognitive deficits involving attention, processing speed, working memory, and executive function, often described by patients as brain fog.

• Sleep disturbance, non-restorative sleep, and circadian disruption.

• Pain syndromes including myalgia, arthralgia, headache, and neuropathic qualities such as burning or paresthesia.

• Gastrointestinal symptoms (nausea, abdominal pain, altered bowel habit), and sensory disturbances (dysgeusia, anosmia, parosmia).

• Symptoms may remit and relapse, and multi-system involvement is common.

Objective findings reported in the literature

• Pulmonary: normal spirometry in many, with subsets showing reduced DLCO or small-airway involvement; cardiopulmonary exercise testing abnormalities including reduced peak VO₂ and ventilatory inefficiency in selected cohorts.

• Cardiac: myocarditis or micro-injury in a minority; sinus tachycardia and heart rate variability changes; autonomic testing consistent with orthostatic intolerance.

• Neurocognitive: deficits on attention and executive function tasks; slowed psychomotor speed; functional MRI and EEG studies with heterogeneous findings.

• Hematologic and endothelial: markers suggestive of endothelial activation, microclot surrogates, and altered coagulation parameters in exploratory studies.

• Immunologic: reports of persistent immune activation, altered cytokine profiles, autoantibodies in subsets, and evidence of viral antigen persistence in tissue in research settings.

• Findings are not uniform and normal routine tests do not exclude clinically significant impairment.

Pathophysiology, leading hypotheses

Multifactorial models predominate. Proposed mechanisms include:

1. Viral persistence or antigen persistence in tissue compartments with chronic immune stimulation.

2. Immune dysregulation with aberrant cytokine networks, autoantibody formation, and incomplete resolution of inflammation.

3. Endothelial dysfunction and microvascular dysautonomia leading to impaired oxygen delivery and exertional intolerance.

4. Autonomic nervous system dysregulation with baroreflex and small-fiber contributions.

5. Mitochondrial and metabolic reprogramming with impaired oxidative phosphorylation under load.

6. Dysbiosis and gut barrier perturbation with systemic symptom links.

   
   

   Relative contribution likely varies by phenotype and over time.

Differential diagnosis domains

Consider alternative or concurrent explanations across domains: cardiopulmonary (asthma, COPD, interstitial lung disease, pulmonary embolism, myocarditis, ischemia), hematologic (anaemia, iron deficiency without anaemia), endocrine and metabolic (thyroid disease, diabetes dysregulation, adrenal disorders), sleep disorders (obstructive sleep apnoea, insomnia), neurologic (migraine spectrum, small-fiber neuropathy), autonomic disorders (primary POTS, neurally mediated hypotension), psychiatric conditions (major depression, generalized anxiety), medication effects, post-critical illness syndromes, and deconditioning. Multiple conditions may coexist.

Natural history and prognosis

Trajectories include gradual improvement over months, relapsing-remitting courses, and persistent symptoms beyond one to two years in a subset. Predictors of slower recovery in reports include female sex, middle age, higher acute severity, comorbidity burden, and presence of multi-system involvement. Functional impairment can persist despite normal routine investigations.

Pediatric considerations

Children can present with fatigue limiting play, exercise intolerance, orthostatic symptoms, headaches, abdominal pain, sleep disturbance, and cognitive complaints affecting school performance. Growth, development, and school participation are the key functional anchors in this group. Objective abnormalities may be subtle and variable.

Terminology and coding

Use consistent clinical terminology such as post-COVID-19 condition or post-acute sequelae of SARS-CoV-2 infection to enable communication, documentation, and surveillance. Record index infection context, dominant symptom clusters, functional status at work or school, and objective abnormalities when present.

Health-system signal

Even with heterogeneous estimates, the aggregate burden is non-trivial across primary care, rehabilitation, cardiopulmonary, neurology, and mental health services. Surveillance, standard nomenclature, and cross-disciplinary literacy improve recognition and reduce misattribution. The central clinical insight is that function can be significantly impaired in the presence of normal conventional tests, and multi-system symptom constellations are expected rather than exceptional.