Long COVID and Health Inequities: The Role of Primary Care

Perspective COVID-19

Policy Points:

  • An estimated 700,000 people in the United States have “long COVID,” that is, symptoms of COVID-19 persisting beyond three weeks.
  • COVID-19 and its long-term sequelae are strongly influenced by social determinants such as poverty and by structural inequalities such as racism and discrimination.
  • Primary care providers are in a unique position to provide and coordinate care for vulnerable patients with long COVID.
  • Policy measures should include strengthening primary care, optimizing data quality, and addressing the multiple nested domains of inequity.

The pandemic has highlighted and exacerbated health inequities in both acute coronavirus disease 2019 (COVID-19) and its longer-term sequelae. Symptoms of COVID-19 persist in approximately one in 10 patients. Acute symptoms include shortness of breath, cough, myalgias, disturbances in the sense of taste and smell, fatigue, fever, chills, and, less commonly, rhinitis and gastrointestinal symptoms. By contrast, the term “long COVID,” coined by patients, refers to both postacute symptoms (lasting more than three weeks) and chronic symptoms (lasting more than 12 weeks). Long COVID is a multisystem disease of unknown cause whose manifestations, while partially overlapping the acute presentation, vary widely among patients and are exacerbated by comorbidities and vulnerabilities. It occurs in adults who were hospitalized and those who were not and (more rarely) in children. At the time of this writing, the United States had more than 17 million diagnosed cases of COVID-19, which translates into approximately 1,700,000 people with long COVID. This does not include the likely underreporting of COVID-19 cases, the proportion of which in one study ranged from one in three to one in 406. The implications for health services are substantial. Given the heterogeneity in definitions of long COVID and the lack of centralized registries of patients with the disease, those who might suffer from long-term symptoms might mistakenly be recorded as recovered.

The natural history of long COVID appears to be gradual improvement over time in most cases, though recovery is typically measured in months. Some patients require comprehensive assessment to exclude serious complications that might underlie their symptoms (notably, thrombo-embolic disease of the lungs, heart, and brain), along with holistic clinical intervention and follow-up. Patients without concerning symptoms should be supported but spared overinvestigation and overmedicalization. Those who have survived admission to an intensive care unit and those with preexisting respiratory, cardiovascular, or cerebrovascular disease are likely to require more specialized and prolonged rehabilitation. Given the paucity of evidence, it is currently unclear which of these issues related to long COVID are directly related to or caused by the disease itself and which are unrelated but may be made more difficult to treat owing to COVID-19 and its after-effects.

Open Access

Citation:
Berger Z, Altiery De Jesus VV, Assoumou SA, Greenhalgh T. Long COVID and Health Inequities: The Role of Primary Care. Milbank Q. 2021;99(2):519-541. https://doi.org/10.1111/1468-0009.12509