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The case study creation process

Types of case studies, benefits and limitations.

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case study , detailed description and assessment of a specific situation in the real world created for the purpose of deriving generalizations and other insights from it. A case study can be about an individual, a group of people, an organization, or an event, among other subjects.

By focusing on a specific subject in its natural setting, a case study can help improve understanding of the broader features and processes at work. Case studies are a research method used in multiple fields, including business, criminology , education , medicine and other forms of health care, anthropology , political science , psychology , and social work . Data in case studies can be both qualitative and quantitative. Unlike experiments, where researchers control and manipulate situations, case studies are considered to be “naturalistic” because subjects are studied in their natural context . ( See also natural experiment .)

The creation of a case study typically involves the following steps:

• The research question to be studied is defined, informed by existing literature and previous research. Researchers should clearly define the scope of the case, and they should compile a list of evidence to be collected as well as identify the nature of insights that they expect to gain from the case study.
• Once the case is identified, the research team is given access to the individual, organization, or situation being studied. Individuals are informed of risks associated with participation and must provide their consent , which may involve signing confidentiality or anonymity agreements.
• Researchers then collect evidence using multiple methods, which may include qualitative techniques, such as interviews, focus groups , and direct observations, as well as quantitative methods, such as surveys, questionnaires, and data audits. The collection procedures need to be well defined to ensure the relevance and accuracy of the evidence.
• The collected evidence is analyzed to come up with insights. Each data source must be reviewed carefully by itself and in the larger context of the case study so as to ensure continued relevance. At the same time, care must be taken not to force the analysis to fit (potentially preconceived) conclusions. While the eventual case study may serve as the basis for generalizations, these generalizations must be made cautiously to ensure that specific nuances are not lost in the averages.
• Finally, the case study is packaged for larger groups and publication. At this stage some information may be withheld, as in business case studies, to allow readers to draw their own conclusions. In scientific fields, the completed case study needs to be a coherent whole, with all findings and statistical relationships clearly documented.

Case studies have been used as a research method across multiple fields. They are particularly popular in the fields of law, business, and employee training; they typically focus on a problem that an individual or organization is facing. The situation is presented in considerable detail, often with supporting data, to discussion participants, who are asked to make recommendations that will solve the stated problem. The business case study as a method of instruction was made popular in the 1920s by instructors at Harvard Business School who adapted an approach used at Harvard Law School in which real-world cases were used in classroom discussions. Other business and law schools started compiling case studies as teaching aids for students. In a business school case study, students are not provided with the complete list of facts pertaining to the topic and are thus forced to discuss and compare their perspectives with those of their peers to recommend solutions.

In criminology , case studies typically focus on the lives of an individual or a group of individuals. These studies can provide particularly valuable insight into the personalities and motives of individual criminals, but they may suffer from a lack of objectivity on the part of the researchers (typically because of the researchers’ biases when working with people with a criminal history), and their findings may be difficult to generalize.

In sociology , the case-study method was developed by Frédéric Le Play in France during the 19th century. This approach involves a field worker staying with a family for a period of time, gathering data on the family members’ attitudes and interactions and on their income, expenditures, and physical possessions. Similar approaches have been used in anthropology . Such studies can sometimes continue for many years.

Case studies provide insight into situations that involve a specific entity or set of circumstances. They can be beneficial in helping to explain the causal relationships between quantitative indicators in a field of study, such as what drives a company’s market share. By introducing real-world examples, they also plunge the reader into an actual, concrete situation and make the concepts real rather than theoretical. They also help people study rare situations that they might not otherwise experience.

Because case studies are in a “naturalistic” environment , they are limited in terms of research design: researchers lack control over what they are studying, which means that the results often cannot be reproduced. Also, care must be taken to stay within the bounds of the research question on which the case study is focusing. Other limitations to case studies revolve around the data collected. It may be difficult, for instance, for researchers to organize the large volume of data that can emerge from the study, and their analysis of the data must be carefully thought through to produce scientifically valid insights. The research methodology used to generate these insights is as important as the insights themselves, for the latter need to be seen in the proper context. Taken out of context, they may lead to erroneous conclusions. Like all scientific studies, case studies need to be approached objectively; personal bias or opinion may skew the research methods as well as the results. ( See also confirmation bias .)

Business case studies in particular have been criticized for approaching a problem or situation from a narrow perspective. Students are expected to come up with solutions for a problem based on the data provided. However, in real life, the situation is typically reversed: business managers face a problem and must then look for data to help them solve it.

The Ultimate Guide to Qualitative Research - Part 1: The Basics

• Introduction and overview
• What is qualitative research?
• What is qualitative data?
• Examples of qualitative data
• Qualitative vs. quantitative research
• Mixed methods
• Qualitative research preparation
• Theoretical perspective
• Theoretical framework
• Literature reviews

Research question

• Conceptual framework
• Conceptual vs. theoretical framework

Data collection

• Qualitative research methods
• Focus groups
• Observational research

What is a case study?

Applications for case study research, what is a good case study, process of case study design, benefits and limitations of case studies.

• Ethnographical research
• Ethical considerations
• Confidentiality and privacy
• Power dynamics
• Reflexivity

Case studies

Case studies are essential to qualitative research , offering a lens through which researchers can investigate complex phenomena within their real-life contexts. This chapter explores the concept, purpose, applications, examples, and types of case studies and provides guidance on how to conduct case study research effectively.

Whereas quantitative methods look at phenomena at scale, case study research looks at a concept or phenomenon in considerable detail. While analyzing a single case can help understand one perspective regarding the object of research inquiry, analyzing multiple cases can help obtain a more holistic sense of the topic or issue. Let's provide a basic definition of a case study, then explore its characteristics and role in the qualitative research process.

Definition of a case study

A case study in qualitative research is a strategy of inquiry that involves an in-depth investigation of a phenomenon within its real-world context. It provides researchers with the opportunity to acquire an in-depth understanding of intricate details that might not be as apparent or accessible through other methods of research. The specific case or cases being studied can be a single person, group, or organization – demarcating what constitutes a relevant case worth studying depends on the researcher and their research question .

Among qualitative research methods , a case study relies on multiple sources of evidence, such as documents, artifacts, interviews , or observations , to present a complete and nuanced understanding of the phenomenon under investigation. The objective is to illuminate the readers' understanding of the phenomenon beyond its abstract statistical or theoretical explanations.

Characteristics of case studies

Case studies typically possess a number of distinct characteristics that set them apart from other research methods. These characteristics include a focus on holistic description and explanation, flexibility in the design and data collection methods, reliance on multiple sources of evidence, and emphasis on the context in which the phenomenon occurs.

Furthermore, case studies can often involve a longitudinal examination of the case, meaning they study the case over a period of time. These characteristics allow case studies to yield comprehensive, in-depth, and richly contextualized insights about the phenomenon of interest.

The role of case studies in research

Case studies hold a unique position in the broader landscape of research methods aimed at theory development. They are instrumental when the primary research interest is to gain an intensive, detailed understanding of a phenomenon in its real-life context.

In addition, case studies can serve different purposes within research - they can be used for exploratory, descriptive, or explanatory purposes, depending on the research question and objectives. This flexibility and depth make case studies a valuable tool in the toolkit of qualitative researchers.

Remember, a well-conducted case study can offer a rich, insightful contribution to both academic and practical knowledge through theory development or theory verification, thus enhancing our understanding of complex phenomena in their real-world contexts.

What is the purpose of a case study?

Case study research aims for a more comprehensive understanding of phenomena, requiring various research methods to gather information for qualitative analysis . Ultimately, a case study can allow the researcher to gain insight into a particular object of inquiry and develop a theoretical framework relevant to the research inquiry.

Why use case studies in qualitative research?

Using case studies as a research strategy depends mainly on the nature of the research question and the researcher's access to the data.

Conducting case study research provides a level of detail and contextual richness that other research methods might not offer. They are beneficial when there's a need to understand complex social phenomena within their natural contexts.

The explanatory, exploratory, and descriptive roles of case studies

Case studies can take on various roles depending on the research objectives. They can be exploratory when the research aims to discover new phenomena or define new research questions; they are descriptive when the objective is to depict a phenomenon within its context in a detailed manner; and they can be explanatory if the goal is to understand specific relationships within the studied context. Thus, the versatility of case studies allows researchers to approach their topic from different angles, offering multiple ways to uncover and interpret the data .

The impact of case studies on knowledge development

Case studies play a significant role in knowledge development across various disciplines. Analysis of cases provides an avenue for researchers to explore phenomena within their context based on the collected data.

This can result in the production of rich, practical insights that can be instrumental in both theory-building and practice. Case studies allow researchers to delve into the intricacies and complexities of real-life situations, uncovering insights that might otherwise remain hidden.

Types of case studies

In qualitative research , a case study is not a one-size-fits-all approach. Depending on the nature of the research question and the specific objectives of the study, researchers might choose to use different types of case studies. These types differ in their focus, methodology, and the level of detail they provide about the phenomenon under investigation.

Understanding these types is crucial for selecting the most appropriate approach for your research project and effectively achieving your research goals. Let's briefly look at the main types of case studies.

Exploratory case studies

Exploratory case studies are typically conducted to develop a theory or framework around an understudied phenomenon. They can also serve as a precursor to a larger-scale research project. Exploratory case studies are useful when a researcher wants to identify the key issues or questions which can spur more extensive study or be used to develop propositions for further research. These case studies are characterized by flexibility, allowing researchers to explore various aspects of a phenomenon as they emerge, which can also form the foundation for subsequent studies.

Descriptive case studies

Descriptive case studies aim to provide a complete and accurate representation of a phenomenon or event within its context. These case studies are often based on an established theoretical framework, which guides how data is collected and analyzed. The researcher is concerned with describing the phenomenon in detail, as it occurs naturally, without trying to influence or manipulate it.

Explanatory case studies

Explanatory case studies are focused on explanation - they seek to clarify how or why certain phenomena occur. Often used in complex, real-life situations, they can be particularly valuable in clarifying causal relationships among concepts and understanding the interplay between different factors within a specific context.

Intrinsic, instrumental, and collective case studies

These three categories of case studies focus on the nature and purpose of the study. An intrinsic case study is conducted when a researcher has an inherent interest in the case itself. Instrumental case studies are employed when the case is used to provide insight into a particular issue or phenomenon. A collective case study, on the other hand, involves studying multiple cases simultaneously to investigate some general phenomena.

Each type of case study serves a different purpose and has its own strengths and challenges. The selection of the type should be guided by the research question and objectives, as well as the context and constraints of the research.

The flexibility, depth, and contextual richness offered by case studies make this approach an excellent research method for various fields of study. They enable researchers to investigate real-world phenomena within their specific contexts, capturing nuances that other research methods might miss. Across numerous fields, case studies provide valuable insights into complex issues.

Critical information systems research

Case studies provide a detailed understanding of the role and impact of information systems in different contexts. They offer a platform to explore how information systems are designed, implemented, and used and how they interact with various social, economic, and political factors. Case studies in this field often focus on examining the intricate relationship between technology, organizational processes, and user behavior, helping to uncover insights that can inform better system design and implementation.

Health research

Health research is another field where case studies are highly valuable. They offer a way to explore patient experiences, healthcare delivery processes, and the impact of various interventions in a real-world context.

Case studies can provide a deep understanding of a patient's journey, giving insights into the intricacies of disease progression, treatment effects, and the psychosocial aspects of health and illness.

Asthma research studies

Specifically within medical research, studies on asthma often employ case studies to explore the individual and environmental factors that influence asthma development, management, and outcomes. A case study can provide rich, detailed data about individual patients' experiences, from the triggers and symptoms they experience to the effectiveness of various management strategies. This can be crucial for developing patient-centered asthma care approaches.

Other fields

Apart from the fields mentioned, case studies are also extensively used in business and management research, education research, and political sciences, among many others. They provide an opportunity to delve into the intricacies of real-world situations, allowing for a comprehensive understanding of various phenomena.

Case studies, with their depth and contextual focus, offer unique insights across these varied fields. They allow researchers to illuminate the complexities of real-life situations, contributing to both theory and practice.

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Understanding the key elements of case study design is crucial for conducting rigorous and impactful case study research. A well-structured design guides the researcher through the process, ensuring that the study is methodologically sound and its findings are reliable and valid. The main elements of case study design include the research question , propositions, units of analysis, and the logic linking the data to the propositions.

The research question is the foundation of any research study. A good research question guides the direction of the study and informs the selection of the case, the methods of collecting data, and the analysis techniques. A well-formulated research question in case study research is typically clear, focused, and complex enough to merit further detailed examination of the relevant case(s).

Propositions

Propositions, though not necessary in every case study, provide a direction by stating what we might expect to find in the data collected. They guide how data is collected and analyzed by helping researchers focus on specific aspects of the case. They are particularly important in explanatory case studies, which seek to understand the relationships among concepts within the studied phenomenon.

Units of analysis

The unit of analysis refers to the case, or the main entity or entities that are being analyzed in the study. In case study research, the unit of analysis can be an individual, a group, an organization, a decision, an event, or even a time period. It's crucial to clearly define the unit of analysis, as it shapes the qualitative data analysis process by allowing the researcher to analyze a particular case and synthesize analysis across multiple case studies to draw conclusions.

Argumentation

This refers to the inferential model that allows researchers to draw conclusions from the data. The researcher needs to ensure that there is a clear link between the data, the propositions (if any), and the conclusions drawn. This argumentation is what enables the researcher to make valid and credible inferences about the phenomenon under study.

Understanding and carefully considering these elements in the design phase of a case study can significantly enhance the quality of the research. It can help ensure that the study is methodologically sound and its findings contribute meaningful insights about the case.

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Conducting a case study involves several steps, from defining the research question and selecting the case to collecting and analyzing data . This section outlines these key stages, providing a practical guide on how to conduct case study research.

Defining the research question

The first step in case study research is defining a clear, focused research question. This question should guide the entire research process, from case selection to analysis. It's crucial to ensure that the research question is suitable for a case study approach. Typically, such questions are exploratory or descriptive in nature and focus on understanding a phenomenon within its real-life context.

Selecting and defining the case

The selection of the case should be based on the research question and the objectives of the study. It involves choosing a unique example or a set of examples that provide rich, in-depth data about the phenomenon under investigation. After selecting the case, it's crucial to define it clearly, setting the boundaries of the case, including the time period and the specific context.

Previous research can help guide the case study design. When considering a case study, an example of a case could be taken from previous case study research and used to define cases in a new research inquiry. Considering recently published examples can help understand how to select and define cases effectively.

Developing a detailed case study protocol

A case study protocol outlines the procedures and general rules to be followed during the case study. This includes the data collection methods to be used, the sources of data, and the procedures for analysis. Having a detailed case study protocol ensures consistency and reliability in the study.

The protocol should also consider how to work with the people involved in the research context to grant the research team access to collecting data. As mentioned in previous sections of this guide, establishing rapport is an essential component of qualitative research as it shapes the overall potential for collecting and analyzing data.

Collecting data

Gathering data in case study research often involves multiple sources of evidence, including documents, archival records, interviews, observations, and physical artifacts. This allows for a comprehensive understanding of the case. The process for gathering data should be systematic and carefully documented to ensure the reliability and validity of the study.

Analyzing and interpreting data

The next step is analyzing the data. This involves organizing the data , categorizing it into themes or patterns , and interpreting these patterns to answer the research question. The analysis might also involve comparing the findings with prior research or theoretical propositions.

Writing the case study report

The final step is writing the case study report . This should provide a detailed description of the case, the data, the analysis process, and the findings. The report should be clear, organized, and carefully written to ensure that the reader can understand the case and the conclusions drawn from it.

Each of these steps is crucial in ensuring that the case study research is rigorous, reliable, and provides valuable insights about the case.

The type, depth, and quality of data in your study can significantly influence the validity and utility of the study. In case study research, data is usually collected from multiple sources to provide a comprehensive and nuanced understanding of the case. This section will outline the various methods of collecting data used in case study research and discuss considerations for ensuring the quality of the data.

Interviews are a common method of gathering data in case study research. They can provide rich, in-depth data about the perspectives, experiences, and interpretations of the individuals involved in the case. Interviews can be structured , semi-structured , or unstructured , depending on the research question and the degree of flexibility needed.

Observations

Observations involve the researcher observing the case in its natural setting, providing first-hand information about the case and its context. Observations can provide data that might not be revealed in interviews or documents, such as non-verbal cues or contextual information.

Documents and artifacts

Documents and archival records provide a valuable source of data in case study research. They can include reports, letters, memos, meeting minutes, email correspondence, and various public and private documents related to the case.

These records can provide historical context, corroborate evidence from other sources, and offer insights into the case that might not be apparent from interviews or observations.

Physical artifacts refer to any physical evidence related to the case, such as tools, products, or physical environments. These artifacts can provide tangible insights into the case, complementing the data gathered from other sources.

Ensuring the quality of data collection

Determining the quality of data in case study research requires careful planning and execution. It's crucial to ensure that the data is reliable, accurate, and relevant to the research question. This involves selecting appropriate methods of collecting data, properly training interviewers or observers, and systematically recording and storing the data. It also includes considering ethical issues related to collecting and handling data, such as obtaining informed consent and ensuring the privacy and confidentiality of the participants.

Data analysis

Analyzing case study research involves making sense of the rich, detailed data to answer the research question. This process can be challenging due to the volume and complexity of case study data. However, a systematic and rigorous approach to analysis can ensure that the findings are credible and meaningful. This section outlines the main steps and considerations in analyzing data in case study research.

Organizing the data

The first step in the analysis is organizing the data. This involves sorting the data into manageable sections, often according to the data source or the theme. This step can also involve transcribing interviews, digitizing physical artifacts, or organizing observational data.

Categorizing and coding the data

Once the data is organized, the next step is to categorize or code the data. This involves identifying common themes, patterns, or concepts in the data and assigning codes to relevant data segments. Coding can be done manually or with the help of software tools, and in either case, qualitative analysis software can greatly facilitate the entire coding process. Coding helps to reduce the data to a set of themes or categories that can be more easily analyzed.

Identifying patterns and themes

After coding the data, the researcher looks for patterns or themes in the coded data. This involves comparing and contrasting the codes and looking for relationships or patterns among them. The identified patterns and themes should help answer the research question.

Interpreting the data

Once patterns and themes have been identified, the next step is to interpret these findings. This involves explaining what the patterns or themes mean in the context of the research question and the case. This interpretation should be grounded in the data, but it can also involve drawing on theoretical concepts or prior research.

Verification of the data

The last step in the analysis is verification. This involves checking the accuracy and consistency of the analysis process and confirming that the findings are supported by the data. This can involve re-checking the original data, checking the consistency of codes, or seeking feedback from research participants or peers.

Like any research method , case study research has its strengths and limitations. Researchers must be aware of these, as they can influence the design, conduct, and interpretation of the study.

Understanding the strengths and limitations of case study research can also guide researchers in deciding whether this approach is suitable for their research question . This section outlines some of the key strengths and limitations of case study research.

Benefits include the following:

• Rich, detailed data: One of the main strengths of case study research is that it can generate rich, detailed data about the case. This can provide a deep understanding of the case and its context, which can be valuable in exploring complex phenomena.
• Flexibility: Case study research is flexible in terms of design , data collection , and analysis . A sufficient degree of flexibility allows the researcher to adapt the study according to the case and the emerging findings.
• Real-world context: Case study research involves studying the case in its real-world context, which can provide valuable insights into the interplay between the case and its context.
• Multiple sources of evidence: Case study research often involves collecting data from multiple sources , which can enhance the robustness and validity of the findings.

On the other hand, researchers should consider the following limitations:

• Generalizability: A common criticism of case study research is that its findings might not be generalizable to other cases due to the specificity and uniqueness of each case.
• Time and resource intensive: Case study research can be time and resource intensive due to the depth of the investigation and the amount of collected data.
• Complexity of analysis: The rich, detailed data generated in case study research can make analyzing the data challenging.
• Subjectivity: Given the nature of case study research, there may be a higher degree of subjectivity in interpreting the data , so researchers need to reflect on this and transparently convey to audiences how the research was conducted.

Being aware of these strengths and limitations can help researchers design and conduct case study research effectively and interpret and report the findings appropriately.

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Case Study Method and Policy Analysis

Cite this chapter.

• Leslie A. Pal  

Case studies are a good part of the backbone of policy analysis and research. This chapter illustrates case study methodology with a specific example drawn from the author’s current research on Internet governance.

Real-world problems are embedded in complex systems, in specific institutions, and are viewed differently by different policy actors. The case study method contributes to policy analysis in two ways. First, it provides a vehicle for fully contextualized problem definition. For example, in dealing with rising crime rates in a given city, the case approach allows the analyst to develop a portrait of crime in that city, for that city, and for that city’s decision makers. Second, case studies can illuminate policy-relevant questions (more as research than analysis) and can eventually inform more practical advice down the road. The chapter reviews the relationship between case study research and the aspirations of more nomothetic (law-like generalizations) social science. To study a case is not to study a unique phenomenon, but one that provides insight into a broader range of phenomena.

The author’s example of ICANN illustrates issues pertaining to globalization, global governance, and the internationalization of policy processes.

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Pal, L.A. (2005). Case Study Method and Policy Analysis. In: Geva-May, I. (eds) Thinking Like a Policy Analyst. Palgrave Macmillan, New York. https://doi.org/10.1057/9781403980939_12

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The role of case study research in political science: evidence for causal claims.

Published online by Cambridge University Press:  01 January 2022

Political science research, particularly in international relations and comparative politics, has increasingly become dominated by statistical and formal approaches. The promise of these approaches shifted the methodological emphasis away from case study research. In response, supporters of case study research argue that case studies provide evidence for causal claims that is not available through statistical and formal research methods, and many have advocated multimethod research. I propose a way of understanding the integration of multiple methodologies in which the causes sought in case studies are treated as singular causation and contingent on a theoretical framework.

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I am grateful to the other participants in the symposium (Mary Morgan, Rachel Ankeny, and Carlo Gabbani) for comments. Comments from participants at the “Reasoning with Cases in the Social Sciences” workshop at the Center for Philosophy of Science at the University of Pittsburgh in November 2011 also helped shape the article.

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• Volume 79, Issue 5
• Sharon Crasnow
• DOI: https://doi.org/10.1086/667869

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How to Study Political Theory

Download PDF Study Guide

A Student Companion to Graham and Hoffman, Introduction to Political Theory

Intended learning outcomes – developing your transferable skills.

University courses have what are called ‘intended learning outcomes’ (ILOs). An intended learning outcome is what a student should be able to achieve on the completion of a course and can be tested through, for example, tutorial/seminar participation, unseen written exams, seen exams (‘takeaway papers’), multiple choice questions, and course essays. There are at least four different kinds of ILO: transferable skills; generic academic skills; cognate academic skills; and, subject-specific skills. This guide concentrates on the last of these: the skills specific to the understanding of political theory (the ‘10 rules’). However, it is worth saying something about the other three kinds of ILO:

Transferable skills

These are skills useful in employment situations. Specifically, the study of political theory should strengthen the following:

• General reasoning abilities – recognising valid and invalid arguments.
• Capacity to make valid conceptual distinctions – the consistent use of concepts.
• Writing skills.
• Oral skills – the ability to argue a case through, for example: (a) defending your own position; or (b) playing ‘devil’s advocate’.
• A deeper understanding of social relations, including the ability to abstract from everyday situations – reflection on ‘case studies’ is particularly important here.
• Ethical reasoning.
• Empathy – the ability to recognise other people’s points of view.

Generic academic skills

These are skills which can be ‘transferred’ to other university subjects, especially in the arts (or humanities) and social sciences. They include the skills listed above under ‘transferable skills’, but additionally:

• The ability to write grammatically and syntactically correct and properly referenced academic essays.
• The capacity to construct arguments under examination conditions – that is, in a specified time and without notes.
• The framing of an oral argument and ability to defend it in group discussion.

Cognate - subject academic skills

Political theory ‘interfaces’ with a number of other disciplines, or sub-disciplines, and skills gained in the study of political theory are ‘transferable’ to these other sub-disciplines. Cognate disciplines and sub-disciplines include:

• History, especially the history of ideas.
• Economics – e.g., welfare economics and rational choice.
• Law – e.g., legal philosophy and legal theory.
• Sociology and anthropology.
• Social and public policy.
• Literature – e.g., textual analysis.
• Biology – e.g., sociobiology.

It is important to recognise that different disciplines pose different questions and these should not be confused. However, it is also important to avoid arbitrary distinctions between disciplines – knowledge, understanding, and skills acquired in one discipline can be transferred to another.

Ten rules for studying political theory

Rule 1: think for yourself.

So long as you acknowledge alternative positions, it is better to present your own arguments rather than a boring list of alternative claims. Have confidence in your own position! There is, however, a difference between presenting your own argument and engaging in a polemic: you must provide a reasoned defence of a particular position. Furthermore, while political theorists disagree, it does not follow that political values are ‘subjective’ – you are giving other people reasons for accepting a certain claim and not simply banging the table and saying (in effect) I feel strongly about something (you can, of course, communicate reasons and feel strongly, but the reasons are crucial).

Rule 2: Use concepts with precision

Concepts are central to all academic disciplines, but especially the humanities and social sciences. Some political theorists claim we can agree on the meaning of concepts, such as (say) freedom or democracy while disagreeing about the value attached to each, or how we settle conflicts between values. Other political theorists argue that disagreement pertains to the meaning, as well as the value, of concepts. Whichever view you take, it is important to define your concepts, even if other people may disagree with your definition. You must also be consistent in your definition and application of concepts.

Rule 3: Recognise the importance of everyday experience

Even before you began studying political theory you had engaged in ‘political theory’: reflections on the fairness or unfairness of wealth distribution, or the legitimacy or illegitimacy of restrictions on freedom, involve theorising about politics and morality. Although few politicians read works of political theory (or philosophy), they often (implicitly) make moral judgements about ‘political issues’. Case studies are a particularly good way of drawing out the moral implications of everyday experience. These contrast with artificial thought experiments, where the aim is quite deliberately to remove contingent elements or to force you to think in a certain way – both case studies and thought-experiments can be useful.

Rule 4: Be critical of everyday assumptions

While everyday experience is valuable – because it demonstrates the relevance of political theory – it is also important to be critical of everyday assumptions. The ‘person in the street’ might say ‘it’s just common sense that such and such is (ought to be) the case’. It may be that after critical reflection you come to endorse the ‘common sense’ view, but then in defending the view you would not be appealing to common sense.

Rule 5: Read texts critically

There is a great deal of published work in political theory, some good and some bad. Even the work of the greatest and most respected political theorists are open to challenge. In studying political theory think of a building. Buildings have ‘stress points’ and ‘loadbearing’ elements, and so do theories – but the precise location of these will vary from one theory to another. When you read a work of a great theorist, such as Hobbes or Locke or Marx, you need to identify the stress points, because these are the points that are most open to attack.

Rule 6: Learn to analyse texts

Continuing with the building analogy, just as a building can be deconstructed so can texts. While it is important to respect the text as a whole rather than pick out the supposedly ‘good bits’ from what may appear to be a great deal of ‘padding’, nonetheless, some sentences carry greater weight than others, and the more you engage with texts the better will be your ability to identify the central arguments.

Rule 7: Engage with the argument

Some theories will appeal to you, others will not – indeed, you may even find some arguments obnoxious. While there is nothing wrong with disliking a theory (see rule 1), it is important to engage with it, which means trying to put the most credible interpretation on it. It is also important to avoid ‘naming’ an argument as a substitute to criticising it: for example, some people might regard the term ‘classical liberal’ as derogatory. They then identify a particular thinker’s work as ‘classical liberal’ as if that were a sufficient ground for rejection. Genuine criticism involves drawing out the truth of an argument – it is not simple rejection

Rule 8: Employ lateral thinking

It may be quite challenging to employ lateral thinking at an introductory level, but some moral problems in politics look intractable because we make false assumptions, or because there are considerations at play which are not obvious from the way the problem is explained (a ‘problem’ is here defined as a puzzle). Lateral thinking involves looking at a problem from new and possibly strange angles. In political theory, the term is rarely used, but nonetheless, there is much lateral thinking, and it often takes the form of analogical thinking – using something from outside politics to explain a political problem. The Prisoner's Dilemma is a classic example, for it helps elucidate the problem of why people who are in profound conflict with one another might cooperate.

Rule 9: Argue cogently and coherently

Arguments in political theory do not always depend on ‘logic’ in the strict sense of the word – that is, conclusions do not follow in a linear manner from a set of premises. There is reliance on empirical claims about the nature of human beings and society, which can reasonably be challenged. Nonetheless, there are standards of cogency and coherence, and while an argument will always be open to challenge, it is usually obvious when a person has advanced obviously contradictory claims.

Rule 10: Form matters

Writing grammatically and syntactically correct sentences is not only an important transferable skill, but can be indicative of cogent and coherent argumentation – form (good writing) and substance (good arguments) are not independent of one another. Writing comes more easily to some students than others, but it is important to take pride in what you write.

Using the Graham & Hoffman resources

This part of the guide explains the various features of the textbook and the Companion Website and how to use them most effectively.

Case studies

Each chapter begins with a case study. Your tutor/instructor will provide further guidance on how to approach them, but there are some general points to be made about the case studies:

• Tackle the case study before you read the rest of the chapter.
• Engage in a ‘brainstorming’ exercise: write down anything relevant to the case under consideration, then:
• Go through the list, deleting what, on reflection, you think is unimportant, and put the remaining points in categories according to the type of argument or claim being made (e.g., factual versus normative, or ‘evaluative’), and then rank the points in order of importance.
• When you have read the chapter, return to the case study and consider whether your views have changed (it may be that your conclusion has not changed, but that you have revised the arguments which lead you to that conclusion).

There are further case studies on this website.

Web resources

Web resources can be found on this website. Obviously the idea of the web is that one website leads to another and your journey through the web may take you to some weird and wacky places. Some academics are quite dismissive of websites, and although this may be partly a reflection of age and generation, there are some dangers with web resources:

• Although a great deal of rubbish appears in print, there is greater ‘quality control’ on books and journal articles than on web-based material. After all, it takes no more than ten minutes to start a blog. On the other hand, there are many intelligent blogs, often with links to interesting articles and websites. Be discerning in your use of web-based materials.
• Arguments should be assessed on their merits rather than ad hominem from their source, but given limited time, there are some tests which can help you discriminate useful and useless websites:
• How well-established is a website? The longer, the better. How many ‘hits’ has it got? The more, the better. How many other websites link to it? The more the better.
• What is the quality of the backlinks (that is, links from the website)? High status web extensions are .edu and .ac.uk.
• Is the material available in published form? Some websites, such as www.jstor.org are, in effect, online libraries, where everything on the website is available in hard copy in university libraries. Other websites contain legal documents, which, likewise, are available published in hard copy.
• You should avoid excessive reliance on websites in writing course essays (see section on writing essays).
• You should not break any laws or regulations in your web search. Some of the topics discussed in the Graham & Hoffman textbooks are controversial, and using certain keywords, such as ‘pornography’, will produce web pages which contravene your college or university regulations, if not laws. The same issue may apply to ‘guns’. If you have any concerns, you should contact your course tutors/instructors.

Further Reading

At the end of each chapter is a guide to further reading. Practices vary between countries, but in Britain lecturers tend to put more items on their reading lists than they expect students to read, with the intention being that students can choose what to read. Items may be more or less relevant depending upon what essay question you are answering. (Furthermore, there can be intense pressure on libraries, so that having a fairly long reading list to some extent reduces that pressure).

In other countries, students assume that everything on a reading list must be read. We have followed the British practice.

Finally: note-taking

Note-taking in lectures and from books is an important skill. Lecturers’ styles and approaches vary greatly – some lecture without notes and/or PowerPoint, while others have detailed notes and overheads which are made available to students. Do not be obsessed with overheads – many lecturers use them simply to give some visual structure to the lecture and it is not intended that students write everything down. It is important to listen to lectures. If you do take notes then consider whether or not a ‘linear’ technique is the best – sometimes ‘trees’ with branches leading from one point to another is better than writing sentences.

Taking notes from books is quite different to note-taking in lectures. Try to avoid writing very long notes – try to condense the argument. If you photocopy from books then avoid underlining or highlighting large chunks – when you come back to the text you want to be able quickly to identify key arguments (do not write in or mark library books!).

Writing essays (papers) in political theory

In this section, we provide guidance specific to writing essays (papers) in political theory.

Some important general points:

• There are no ‘model answers’ to essay questions – two students can answer the same essay question and both get A grades, but their essays may be very different in style and argument.
• Answer the question asked and not a question you would like to have been asked – be relevant!
• You should express your own reasoned views.
• You should develop your own style of writing, but pay attention to grammar, syntax and spelling.
• Think about the structure of the essay.
• Read carefully and with discrimination – develop note-taking skills. Do not read too much.
• Organise your time – there may be many students on your course and a great deal of pressure on library and computing services.
• Be aware that plagiarism is a serious offence.

Essays should have a beginning, middle, and end. Very roughly speaking, the beginning, or opening part, should constitute about 10-15% of the essay and tell the reader what the essay is going to say. The middle part, or ‘core’, should be about 70% of the essay and contain the central arguments and discussion, while the end, or concluding part, should provide a strong conclusion, and may be slightly longer than the opening part (say, about 20% of the essay).

Here is an example, but please note this is not presented as a ‘model answer’, but rather is intended to be an illustration of a well-structured essay:

Question: Should the state prevent people harming themselves?

• Introduction and Core:

• Define the concepts in the question: state (= coercive); prevention (= interference); harm to self.
• Introduce the concept of paternalism.
• Discuss ‘extreme cases’ of harm to self. Pose the question: could anyone reasonably argue that the state should not intervene?
• Is there a danger of a ‘slippery slope’ from extreme to ‘moderate’ cases of harm to self? Discuss the ‘moderate’ cases.
• Could we consent to paternalism?

• Closing part: tell the reader what you think – but the conclusion must follow from the arguments set out in the 'core'.

Referencing – house style

Different academic departments recommend different forms of referencing (‘house styles’). A relatively easy one to use is the Harvard System, which is the one adopted in the Graham & Hoffman textbooks.

Whatever style you adopt, you should:

• Use a house correctly and consistently – if you are unsure look at a book on the Further Reading lists and follow its style of referencing.
• Always reference – failure to reference may open you to the charge of plagiarism.

Other style issues include:

• Margins and spacing – always give the marker space to write comments. There should be reasonably sized margins and at least 1.5 spacing, if not double spacing.
• Font – use a clear and attractive font. Arial, Calibri and Times New Roman are good fonts.
• Use a reasonable font size – the size will depend on the font used, but anything smaller than 11 point is probably too small.
• Avoid excessive use of bullet points.
• Depending on the length of the essay, it may be appropriate to divide the essay into sections with section headings. A section should run for at least a couple of pages.

Grammar, syntax and spelling

Do not assume spelling and grammar checks are infallible – there are many mistakes which they will not identify. There is no alternative to checking the essay yourself. Below are listed some common errors made in politics and political theory essays:

• English, like any other language, has different ‘registers’: using English in an academic essay is quite different to using it in a bar. This is obvious. However, sometimes there is a slippage between levels. For example, in lower registers, such as conversation, we contract: I am becomes I’m ; they are becomes they’re . In higher registers, such as essay writing, we avoid such contractions. Likewise, colloquialisms should be avoided.
• Use of the ‘first person’: I and we . There is a division of opinion here – in political theory it is common to write in the first person (single or plural), whereas in political science it is not regarded as good practice. So long as the use of the first person does not lead to a lazy spouting of unjustified claims it is acceptable.
• Confusion of possessive and plural – this arises because both use the s. The possessive uses apostrophe + s: Mill's argument not Mills argument . The plural does not use an apostrophe: workers of the world unite not worker’s of the world unite. Regular plural + possessive is expressed with an apostrophe after the s: workers’ rights (but not with irregular plurals: women’s rights not womens’ rights ).
• Its and it’s : its is a possessive pronoun – the government’s policies = its policies. An apostrophe is not necessary because there can be no plural of it and hence no confusion of plural and possessive. It’s is simply a contraction of it is .
• Latin and Greek endings: the standard ‘Anglo-Saxon’ ending is with s but as well as Anglo-Saxon irregulars, such as women, children, mice, geese, there are also Latin and Greek endings: criter ion > criter ia ; strat um > strat a ; spectr um > spectr a . However, there is a tendency to standardise: referend um > either referend a or referend ums (both are now acceptable, although the Oxford English Dictionary argues that referendums is the correct plural). If unsure, check the plural in the dictionary.
• Principle and principal are often confused.
• Some people write loose , when they mean lose .
• There and their are sometimes confused.
• A normal sentence should have a verb (in the indicative): Mill attempts to reconcile utilitarianism and individual rights.
• Number agreement. A subject in the singular should correspond to ('govern') other elements (verbs, pronouns) in the sentence – so a singular subject should be complemented by a verb and pronoun in the singular.
• Subjunctive: this is a mood of the verb which expresses an unreal condition. It has virtually disappeared from the English language but is retained in the verb to be: if I were a woman not if I was a woman.

Paul Graham

Revised July 2022

1.1 Defining Politics: Who Gets What, When, Where, How, and Why?

Learning outcomes.

By the end of this section, you will be able to:

• Define and describe politics from various perspectives.
• Identify what makes a behavior political.
• Identify and discuss the three core elements of any political event: rules, reality, and choices.
• Define and discuss varieties of constitutions.

Politics has existed as long as humans have faced scarcity, have had different beliefs and preferences, and have had to resolve these differences while allocating scarce resources. It will continue to exist so long as these human conditions persist—that is, forever. Politics are fundamental to the human condition.

Politics means different things to different people. Politics , and related terms like political and politician , can have both positive and negative connotations. The Greek philosopher Aristotle argued that humans were “political animals” in that only by engaging in politics could humans reach their highest potential. 5 Yet often, the terms political and politician can be used in disparaging ways to refer to individuals using trickery or manipulation to obtain or preserve their status or authority. More formally, a politician is someone running for elective office or serving in it or as a person who is using the skills of a politician in other social interaction. A political actor is anyone who is engaged in political activity. Politics involves all the actions of government and all the people who work for, serve, or challenge it.

This book takes the broadest view, adopting the guidance of political scientist Harold Lasswell , who defined politics as “who gets what, when, how.” 6 Politics exists wherever people interact with one another to make decisions that affect them collectively. Politics exists within families. When parents decide where the family will live: politics. The family (who) gets a place to live (what) at the point of decision (when) based on the parents’ choice (how). When your school decides what tuition to charge: politics. When the government imposes taxes or funds education: politics. Most generally, politics is any interaction among individuals, groups, or institutions that seek to arrive at a decision about how to make a collective choice, or to solve some collective problem. Political science focuses primarily on these interactions as they involve governments. 7

Every political event is different. The mass protests in Hong Kong in 2020, inspired by those seeking to protect their political rights, were not exactly the same as the Black Lives Matter protests in the United States or the climate change actions animated by Swedish environmental activist Greta Thunberg . Yet as varied as political situations can be, there are commonalities across these events and over all political activities. Whenever you seek to understand a political event—whether an election in Tanzania, a protest in Estonia, or a public health program in Indonesia—it is useful to focus on the following:

What are the most important rules ? What is the reality of the existing event or environment? What choices do the participants make? Political outcomes—for example, which candidate wins an election—are based on the interaction of these rules, realities, and choices.

The importance of rules in politics or in life cannot be overstated. In virtually every human endeavor, the most successful individuals are likely to have a keen knowledge of the rules and how to use (or break) the rules to the advantage of their cause. Ignorance of the rules makes accomplishing your goals more difficult.

Rules can be highly precise or open to interpretation. In chess, for example, the rules are completely known to all players: each piece can move in certain directions but in no other ones. Each player takes a turn; that’s the rule. Although chess is highly complex, each player’s options at any given time are known. Chess champions—in fact, all champions—know how to use the rules to their advantage.

College campuses have their own sets of formal and informal rules, and not all of them are as precise as those in chess. The de jure rules are the rules as they are written, the formal rules. The de facto rules are the ones actually practiced or enforced, the informal rules. For example: a sign might state that the ( de jure ) speed limit is 55 miles per hour, but if police do not give tickets to drivers unless they are driving 65 miles per hour, then that is the de facto rule. To thrive at college, it is useful to understand not only the formal rules but also the informal rules, which have been called “the hidden curriculum.” 8

The rules in any political environment affect who has power and how they can use it. Consider the rules that determine who can vote and how. These rules can be permissive or strict, making voting either easier or harder to do. The harder it is to vote, the fewer people will actually cast their ballots and vice versa. Voting rules influence who shows up to vote. Politicians who believe they have a better chance of success under permissive voting rules are likely to advocate for such rules, while politicians who believe they are more likely to prevail under restrictive voting rules will advocate for them instead.

Rules might appear to be neutral—that is, they may seem fair and not designed to favor one group over another—but this is not entirely true. Until recently, to become a pilot in the US Air Force, a person had to be no shorter than 5 feet 4 inches and no taller than 6 feet 5 inches: the short and the tall were excluded from this opportunity. The rule might be in place for a good reason—in this case, to ensure that pilots can fit properly into their seats—but rules like these allocate opportunities and resources to some while withholding them from others. Because this rule excluded over 40 percent of American women from becoming pilots, it has been modified. 9

Rules are everywhere in politics. Your family has rules—even if the main rule is “no rules”—as does your school. Rules, such as Robert’s Rules of Order , 10 govern legislatures, and the criminal justice system, the tax system, and the national immigration systems are all based, at least in principle, on rules.

Rules and institutions are closely related. The institution of marriage or the institution of the family, for example, are the sets of rules (rights, roles, and responsibilities) by which those within the marriage or family live. Alternatively, institutions can be organizations, which are groups of people working together for a common purpose whose actions are governed by rules.

Perhaps the most important set of rules for any institution or organization is its constitution . The constitution affirms the most basic legal principles of a country or a state. These principles typically include the structure of the government, its duties, and the rights of the people. Constitutions can be quite general or extremely detailed. The Constitution of Monaco has fewer than 4,000 words, while the Constitution of India has nearly 150,000 words. 11 Unlike the United States, some countries, including Canada, New Zealand, and the United Kingdom, do not have a single document they call the constitution but instead rely on other written and even unwritten sources. In most countries the constitution is called just that—the constitution—although Germany, Oman, Saudi Arabia, and a few other countries call their constitutions the basic law. 12

What Is a Constitution?

Constitutions define the relationship between people and their government. They give powers to and place limits upon the government and serve as the basis for any other laws or government activities.

Constitutions are perhaps the most important set of rules in a country because, after all, they are just pieces of paper. The true importance of a country’s constitution depends on the politics of that country. In the United States, the Constitution is venerated almost as if it were a religious document. Most of the biggest conflicts throughout US history have involved disputes over what the Constitution requires, allows, or prohibits. When the US Supreme Court rules that a political action is unconstitutional, the violator—whether it be the president, the Congress, or any other group or individual in society—is expected to comply with the ruling and stop the action. 13 But this is not always the case everywhere. Politicians in any country may be tempted to ignore their constitutions, especially when it comes to the rights they ostensibly guarantee, and whether those politicians prevail depends on whether other political actors are willing and able to uphold the constitution.

Because rules affect the allocation of power and other scarce resources, political actors spend substantial time and effort fighting over them. In general, political actors seek to establish rules that benefit them and their allies.

Rules guide and constrain behavior, but the reality on the ground at any specific time also impacts political outcomes. Reality —facts—is not a matter of opinion, although people can dispute the nature of reality. Something is a fact , for example, when there is compelling evidence that an event has happened or a condition exists. The sun rises in the East: reality. The United Nations is an international organization: fact (reality). 14 Has the United Nations made the world a better place? That is a matter of opinion, although those who say “yes” or “no” can provide facts that support their views about reality. 15

How candidates can raise and spend money on their electoral campaigns may be limited by campaign finance laws, but if one candidate raises twice as much money as the other candidate, that is an important fact. If one candidate is the incumbent —a politician already serving in office and running for reelection—and the other is not, that is an important fact. These are important facts because whether or not a candidate is an incumbent and how much campaign money they raise may affect their chances of winning the election. In US elections, for example, incumbents generally have a better chance of being elected (although the strength of this relationship has varied over time), while the impact of fundraising on electoral success is open to question. 16

In chess, the rules are constant, never changing during the game. The reality changes as play proceeds—at any moment each player has a specific number of pieces in particular places on the board. What happens then depends on the choices the players make. This is as true for politics as for any other game. A key difference between chess and politics is that, in politics, the players themselves can change the rules of the game while they are playing.

Politics can be thought of as having the characteristics of a game. The players—anyone involved in political action—make strategic choices, given the rules and the current conditions, in an attempt to “win” the game by obtaining their goals.

Rules provide constraints and opportunities. Reality presents resources and challenges. The choices participants make in the face of rules and reality determine political outcomes. Choice exists whenever political actors face options, which they always do. If there are two candidates in an election for a single position, the voter has to choose between them, not being able to vote for both. Even if there is only one candidate, the voter still has an option: to vote for the candidate or to abstain.

In a democracy , the winning candidate wins because more voters chose to vote, and vote for that candidate, than for other options. The very definition of democracy is that it is a form of government in which the people have the ability to choose their leaders or, in some cases, the policies that they will adopt. 17

Political outcomes are always contingent; they cannot be predicted with certainty in advance. That does not mean, however, that outcomes are completely unpredictable. By accounting for the rules, how human behavior works, and existing realities, it is possible to reasonably predict what is likely to happen and explain what does happen.

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Looking for long covid: a clash of definition and study design.

Yves here. Even though this article is for the most part highly informative, it seems to be unduly inclined to take the point of view that there must be biomarkers, a well-understood pathological process, and/or a tidier set of symptoms. It seems to be a lapse this piece does not even mention chronic fatigue syndrome. For many years, patients who suffered from it were treated as being hypochondriacs or having some other psychological ailment. The two people I knew personally with chronic fatigue were high energy, highly respected professionals with good personal relationships. And there were no obvious triggers for their onset of chronic fatigue.

So it strikes me as medical researcher arrogance to think they can or should be able to get their arms around a new set of pathologies quickly, when there are many that have been around for a long time that we still don’t understand well, from sudden infant death syndrome to Alzheimers to chronic Lyme disease (which some medical professionals claim does not exist).

By Sara Talpos, a contributing editor at Undark. Originally published at Undark

In January, the physician-scientist Ziyad Al-Aly delivered a harrowing message to a U.S. Senate committee. Eyes wide, eyebrows lifted above a tan face mask, he catalogued the body parts at risk of damage from long Covid: the brain, the heart, the gut, not to mention hormones and the immune system. The condition strikes the young and the old, he warned, and one’s personal risk never goes away. “Even if people emerge unscathed after having the first infection,” he told the Senate , “they can still get long Covid after reinfection.” Recovery rates are low, he continued, and without prevention and treatment, the disease’s burden will continue to mount.

From positions at Washington University in St. Louis and at the Veterans Affairs St. Louis Health Care System, Al-Aly has emerged as one of the world’s most cited experts on long Covid. He and his colleagues at VA St. Louis have published in prestigious journals, and online biographies suggest that Al-Aly has served on several U.S. government committees, as well as a high-profile panel that looked at how long Covid can impair a person’s ability to work or attend school. In May, Time named him one of the 100 most influential people in health.

That influence has made Al-Aly and the VA St. Louis group standard-bearers for a particular view of long Covid, one shared by many clinicians and public health officials. It frames the post-viral condition as encompassing hundreds of symptoms and diseases and posing a significant threat to the United States. Speaking to the Senate committee, Al-Aly said that at least 20 million Americans suffer from long Covid; the condition, he added, has caused as much disease and disability as cancer and heart disease.

Al-Aly has earned praise for bringing much-needed data to an underrecognized condition. His studies reflect “what I and my colleagues see on the ground in clinical practice,” said Svetlana Blitshteyn, a neurologist and director of the Dysautonomia Clinic in Buffalo, New York. The cardiologist Eric Topol, an occasional Al-Aly co-author and director of the Scripps Research Translational Institute, called Al-Aly’s work with VA data “as good as it gets.” And Al-Aly has become a go-to expert for the disease, presenting his views about the threat in numerous news articles and opinion pieces.

Few experts dispute that long Covid can be debilitating, or that it warrants careful study. But in interviews with Undark, a number of experts said that it is misleading to frame long Covid as an increasing threat. The best data, they say, suggest that most people recover from the disorder and that long Covid rates will decline as people develop immunity. (A July study by the VA St. Louis team also found that rates of long Covid declined over the course of the pandemic.)

The work produced by Al-Aly and his colleagues, which relies on electronic health records of U.S. veterans, is also a key point of contention. In interviews, several experts questioned the VA St. Louis’ methods. At the request of Undark, Harvard epidemiologist Marc Lipsitch reviewed the group’s first long Covid study and raised a range of concerns. Many of them related to the handling of negative controls , a statistical technique that, when deployed properly, can help researchers detect problems in the analysis of their dataset. Some of the negative controls “are simply misused in the paper,” Lipsitch wrote in an email to Undark.

Additionally, some experts suggested that the VA St. Louis studies are not truly measuring long Covid. “They’re not studying post-viral illness, in my opinion, in these VA studies,” said Anders Hviid, a professor at the University of Copenhagen and head of the Department of Epidemiology Research at the Statens Serum Institut. Post-viral syndromes, said Hviid, are relatively rare and are usually characterized by fatigue and cognitive difficulties. Al-Aly’s research, meanwhile, looks at what Hviid described as a gamut of outcomes: dementia, thromboembolisms, psychiatric diseases, kidney diseases — “everything under the sun,” he said.

At best, the studies are detecting health problems known to occur when people with poor baseline health experience a severe infection of any kind, said Hviid. At worst, the findings simply reflect bias in the study design, and are picking up on symptoms that are not caused by Covid-19 at all. “It’s a disappointment that not more U.S. scientists have spoken up about this,” said Hviid.

The differing viewpoints stem in part from the difficulty of studying a disease that doesn’t have a known biomarker — something measurable in the body’s fluids or tissues that can distinguish patients with long Covid from everyone else. Instead, many researchers have turned to data from medical records and surveys. But the process of gathering and interpreting such data is not straightforward. To date, studies have yielded vastly different answers to seemingly basic questions, including the number of people living with long Covid and the likelihood of recovery.

Between these deep divisions are long Covid patients desperate for clear answers. These patients, Al-Aly suggested in a series of interviews with Undark, are a central motivation. The VA St. Louis findings have been peer reviewed and reproduced in various settings, Al-Aly said, and he pointed to what he views as severe limitations in some studies that have yielded results that run counter to his own. He also cautioned that an overly narrow definition will exclude some patients from research and medical care. “We favor a more inclusive approach,” he said. (Al-Aly did not directly respond to a list of emailed questions about his team’s use of negative controls, or to what some experts suggested were other methodological inconsistencies in the team’s research.)

An inclusive approach to long Covid was recently recommended by a report published in early June by the U.S. National Academies of Sciences, Engineering, and Medicine, which advised physicians to consider a long Covid diagnosis with any new or worsening symptom or disease lasting at least three months and occurring after a SARS-CoV-2 infection. The report did not state specifically how much time might elapse between the Covid infection and the appearance of long Covid.

According to some researchers who spoke with Undark, the report’s broad definition rests on shaky evidence, could complicate clinical trials, and may end up trivializing long Covid. But Al-Aly, who served as a reviewer of the National Academies report, said that the challenges of using a broad definition can be addressed through sub-phenotyping, or the clustering of patients based on symptom patterns. One way to think about this, he said, is to look at the history of cancer: Initially every lump was simply viewed as a tumor, but as science evolved, researchers learned to differentiate between hundreds of different cancers.

Taking this broad approach to long Covid, he suggested, is “really the right thing” to do.

Almost from the start, long Covid proved vexingly difficult to measure and track. Early on, researchers would survey people in the months after a Covid-19 infection and ask if they were experiencing symptoms like fatigue or shortness of breath. Most said yes: A systematic review analyzing papers published during the pandemic’s first year estimated that nearly 75 percent of people developed at least one persistent symptom, or what could now be considered long Covid. That figure “just doesn’t pass the sniff test,” said Michael Putman, a rheumatologist and research methodologist at the Medical College of Wisconsin.

The problem, said Putman, is that symptoms like fatigue are extremely common, including among people who had not caught Covid-19. Those early studies were picking up on lots of symptoms that had nothing to do with the virus, in addition to some actual long Covid cases.

In order to figure out which symptoms are connected with a Covid-19 infection, researchers need to create a comparison, or control, group comprised of people who have not yet been infected. But many of the earliest long Covid studies didn’t do this. “There’s a lot of research that was done very poorly, that has seeded the literature with nonsense,” said Putman.

Al-Aly was part of a wave of researchers who launched more ambitious studies, with control groups, in an attempt to get a better handle on the scope of long Covid. In a recent interview with Undark, Al-Aly recalled a March 2020 Zoom call with his team at the VA. “We saw the world in crisis, the house on fire,” he said. “What do we do — do we sit by the sideline and chew gum and watch TV and watch TikTok?” His team wanted to pitch in by identifying key unanswered questions to study.

Not long after the meeting, people began showing up in clinics, said Al-Aly, sometimes weeks after an initial infection, reporting that they had not fully recovered. They were struggling with a range of symptoms, including fatigue, brain fog, shortness of breath, and persistent coughing. Patients were also finding each other online, and by the summer of 2020, they had coined and adopted the term long Covid to describe their condition. Here, said Al-Aly, was an issue that the public cared about — and that his team could help with.

They had access to an incredible trove of data: the electronic health records for millions of patients in the VA system. Al-Aly had previously used VA data to study the health effects of air pollution and to identify potential side effects of common medications. This earlier research was like a rehearsal, he said, one that prepared him to respond to the pandemic.

He and his colleagues soon launched their first long Covid study. They took a group of more than 87,000 VA patients who had tested positive for Covid-19, and then compared their health records with those of a control group with no record of infection. As it turned out, people who had caught Covid-19 were likelier to die in the six months following their illness than people who had never tested positive. Their health records also showed that, in the months after catching Covid-19, they registered a range of diseases, symptoms, and prescriptions, including for opioids and antidepressants, at higher rates than people who didn’t have a documented case of the illness.

The study additionally found a now well-established pattern: Patients who had spent time in the intensive care unit, or ICU, were at higher risk than those who had been hospitalized but had not been admitted to the ICU. Those who had not been hospitalized at all were at the lowest risk of persistent symptoms.

The paper was published online in April 2021 in the journal Nature and received widespread media attention. “‘Long Hauler’ Study Shows Covid Can Kill Months After Infection,” read one headline .

The VA team followed up with more studies. One 2022 paper found that patients with a documented Covid infection had elevated rates of neurologic diseases , including stroke, depression, and anxiety, as well as movement and cognition disorders. The paper itself noted that the research was conducted mostly in White men, which may limit its ability to speak to the wider population of Americans. That nuance, though, was lost in a press release from the Washington University School of Medicine in St. Louis, which extrapolated the study’s findings to the entire U.S. population, warning that 6.6 million people “have suffered brain impairments associated with the virus.”

At a time of pitched battles over Covid-19 policies, such eye-catching claims found an audience. Al-Aly’s work propelled him into the public spotlight, where he used his platform to sound an alarm: Long Covid was a public health crisis and its effects would have a profound and lasting effect on large swathes of American society. In a 2021 interview with Bloomberg , Al-Aly warned about deteriorating mental health: “Let’s not act surprised two years down the road, when people start committing suicide.”

“We’re seeing brain problems in previously healthy individuals and those who have had mild infections,” Al-Aly told Psychology Today in September 2022. “It doesn’t matter if you are young or old, female or male, or what your race is. It doesn’t matter if you smoked or not, or if you had other unhealthy habits or conditions.” About a month later, in The Washington Post , he compared the risk of a second Covid infection to the risk of playing Russian roulette.

But even as Al-Aly was becoming a public figure, other experts were looking at his methods and raising questions, including a basic one: Should all of these symptoms and conditions — obesity, pressure ulcers, urinary tract infections, asthma — really be considered long Covid?

For more than a century, physicians have known that viral infections are sometimes followed by mysterious, long-lasting symptoms. But defining those illnesses has been a persistent challenge.

In contrast to a well-defined disease like cancer, there’s no blood test or imaging technique that can reliably differentiate people with and without a post-viral illness. Instead, researchers collect data on symptoms and then use the results to create what’s known as a case definition : a set of criteria that allow clinicians and researchers to determine whether someone does or doesn’t have the condition.

In the fall of 2021, the World Health Organization adopted a long Covid case definition . According to the WHO, anyone with a symptom that persists or develops three months after an initial Covid-19 infection, and that can’t be otherwise explained, could be described as experiencing long Covid. Soon after, a group led by Terence Stephenson, a pediatrician and professor of child health at University College London, developed a similar definition for adolescents that could be used for research purposes.

To arrive at its definition, Stephenson’s team gathered researchers, along with parents and caregivers, and then used a consensus approach. There was some tension in the process, said Stephenson. Parents and caregivers felt that one life-altering symptom should be enough to constitute long Covid; whereas researchers and clinicians wanted to limit the diagnosis to patients with more than one serious symptom. The parents and caregivers won the debate. “We ended up with what I would call a very permissive definition,” said Stephenson, who said he stands by the consensus process. (A version of the definition was ultimately adopted by the WHO.)

A 2023 study points to the potential problems with a broad case definition, however. The study used the WHO definition to evaluate 467 people ages 12 to 25 who received a Covid test. The study participants were evaluated early on and then again at six months. As it turned out, nearly half the people who had Covid-19 would meet the WHO criteria for long Covid — but so would nearly half the people who had never been infected with the virus.

The study’s lead author, Joel Selvakumar, a pediatrician and Ph.D. student researching long Covid at the University of Oslo, said the findings generated a polarized response on social media. That’s because of what he characterized as two strident groups with opposing views: One thinks Covid is a hoax, while the other thinks researchers and governments are covering up the disease’s severity. The polarization seems especially intense in the U.S., he observed, and it obscures the underlying issue: At least for studies like his, the current case definition is unreliable.

Unlike Al-Aly’s studies, Selvakumar’s study excluded hospitalized patients. That’s partly because young people are rarely hospitalized due to Covid, he said, but also because any lingering symptoms might be caused by a different underlying mechanism, such as direct tissue damage from severe infection.

Symptoms that develop post-infection are not always due solely to the infection itself. Hospitalization for any reason increases a person’s risk for a wide range of medical problems after discharge. Such problems may have little to do with the initial diagnosis and instead stem from the stress of a hospital stay: The disrupted sleep, poor nutrition, and lack of exercise can all contribute to the onset of new health problems. Additionally, people who are very sick do not always fully recover, and their lingering symptoms are often not specific to the initial illness.

“We have names for those syndromes already,” including post-intensive care syndrome and post-hospitalization syndrome, said Anil Makam, a hospital medicine physician at the University of California, San Francisco, who studies patients in long-term acute care hospitals, where many patients go after an ICU stay. Makam recently published a study that used validated surveys as well as interviews to understand the long-term outcomes of patients who were hospitalized with the most severe cases of Covid-19. His study didn’t have a control group, he said, but the results echo what was known before the pandemic: The sicker the patient, the more likely they are to have persistent multisystem disabilities.

It doesn’t make sense to conflate these conditions with long Covid, he said. Lumping everything together leads to a distorted view of long Covid, and it could complicate efforts to understand the underlying mechanisms and identify possible interventions. “You’re just going to be on a wild goose chase to find treatments,” he said.

Some experts said a broad definition could be useful in the context of public health and epidemiology. Sharon Saydah, an epidemiologist at the Centers for Disease Control and Prevention, said that when CDC scientists crafted the agency’s long Covid definition, they wanted “to make sure we’re not missing anything, that we’re including everyone who might be experiencing ongoing symptoms or new conditions” related to a Covid-19 infection. In a 2021 opinion piece for The Guardian, Al-Aly criticized the WHO’s definition for excluding new onset diseases, such as diabetes and heart disease, which his own studies have detected. These new conditions should count as long Covid, he wrote; otherwise, governments may fail to prepare for “the tide of patients with these chronic conditions.”

(In an email to Undark, a WHO spokesperson, Tarik Jasarevic, wrote that its definition may include new onset disease: The definition “focuses on symptoms but doesn’t specifically exclude new onset disease. New onset conditions like diabetes, lupus, stroke, etc. may be considered” long Covid, Jasarevic wrote.)

At stake, Al-Aly suggested, is a broader struggle: That of long Covid patients who seek to have their symptoms taken seriously, but may encounter skepticism from peers, employers, and caretakers. “I worry that this myopic definition of long Covid may be used by governments and health insurers to debase the disease and deny insurance coverage,” he wrote. “It may add fuel to the gaslighters’ fire, providing them with a moral license to sow more skepticism around the existence of this disease.”

In an interview with Undark, he said that for too long post-infectious illnesses were marginalized. Then, when pandemic hit, the health care system was caught flatfooted. There is no national medical society to champion patients’ cause, and individual physicians are unsure about how to help, he said. Congress allocated more than $1 billion in 2021 to fund long Covid research (and the government kicked in an additional $515 million this year). That’s a start, said Al-Aly. But it’s nowhere near enough.

In the spring of 2021, after Nature published Al-Aly’s first long Covid paper, Anders Hviid’s first reaction was surprise. Nature is a top journal, but it was unusual for the publication to feature epidemiology, said Hviid. Even more unusual were the study’s findings. “It’s just difficult to imagine that a simple respiratory virus could be so detrimental to all organ systems at a population-level scale,” said Hviid. One’s intuition can always be wrong, he added, but given that other respiratory infections, including influenza, do not exact such a massive toll, skepticism seemed like the right starting point: “You should question, ‘Can that be right?’”

For more than two decades, Hviid has conducted research using Denmark’s centralized medical records. During the pandemic, he and his colleagues used electronic health record data to conduct vaccine safety and effectiveness studies. And by late 2020, he had also turned his attention to long Covid, securing funding for a study that would survey the Danish population about their post-Covid symptoms. Such questionnaires offer fine-grained data that can be difficult, if not impossible, to obtain through electronic health records, said Hviid. Nevertheless, Al-Aly’s study had piqued his curiosity. He decided to conduct EHR-based studies as well.

This February, he and four colleagues published a study using medical records of the entire Danish population aged 12 and over. In contrast to Al-Aly’s work, that study found no evidence of substantial neurological or psychiatric symptoms in non-hospitalized individuals one year after a Covid-19 infection.

A defining feature of the study, said Hviid, is its high number of mild or asymptomatic infections. These were documented thanks to the country’s widespread surveillance testing . People getting tested in Denmark were often young and healthy. They got tested because it was a requirement for socializing.

Hviid’s team did see a meaningful increased risk of persistent symptoms among those who had been hospitalized. “That’s not particularly surprising,” he said. A severe course of any illness can lead to lingering effects.

Hviid and his colleagues aren’t the only researchers to find that long-lasting Covid-19 symptoms are rare for people with mild illness. A 2023 study looked at the electronic health records of a nationally representative sample of Israeli citizens with mild cases of Covid-19. It found that they were “at risk for a small number of health outcomes.” But most of the symptoms resolved within a year.

That study “confirms the statements that we’ve made that by and large, by one year, most people will have recovered,” said Theo Vos, an epidemiologist who helps track long Covid for the long-running Global Burden of Disease study.

Vos is an author of a 2022 systematic review that pooled data from 54 studies and two medical records databases, then grouped study participants into three symptom clusters: one centered around fatigue, another around cognition, and a third around breathing problems. The authors found that, among non-hospitalized people, just 0.7 percent had not recovered by 12 months after infection. This compared with 11 percent of those who were hospitalized and around 20 percent of those whose hospital stay involved the ICU.

In an April email, Selvakumar pointed out that many early long Covid studies were conducted on non-immune populations. That’s important to keep in mind, he wrote, because “the largest risk factor for long Covid is initial severity.” Thanks to immunity from vaccines and prior infection, most people today are less likely to have a severe course of the illness — thus, their risk of long Covid has declined as well.

Comparing an Al-Aly study of mental health outcomes with Hviid’s offers a glimpse into the dizzying number of variables that can influence a study’s results — even when, on the surface, the studies appear similar.

“There are huge differences” between the two studies, said Jeffrey Morris, director of the Biostatistics Division at the University of Pennsylvania’s Perelman School of Medicine. He started ticking them off: different study populations, different designs, different time periods.

Both approaches, Morris said, had merit.

Other researchers agreed that Al-Aly’s studies have merit, but stressed that the work is limited in its ability to speak to long Covid in the broader population. As a group, VA patients are older and less healthy. As a result, they are at higher risk of severe infection that might lead to hospitalization or even a stay in the ICU, events that increase one’s risk of long Covid. The VA studies look at “a very special group of high-risk people,” wrote Selvakumar in an email, “so you have to be very careful when extrapolating to the general population.” While a given study may note this limitation, he continued, the caveat sometimes gets lost in what he characterized as media spin.

One researcher doing similar studies was cautious about extrapolating his findings to the broader population. Junqing Xie, a post-doctoral researcher at the University of Oxford, recently co-authored a paper that used data from the U.K. Biobank to look for a connection between a Covid infection and psychiatric disorders and prescriptions. Similar to the VA team, Xie’s team found a link. However, it’s unclear what precisely this means for the general population, said Xie. “We are not able to infer any prevalences,” he told Undark. To do that, a researcher would need to ensure that their study participants are highly representative of the broader population. Neither the BioBank nor the VA databases meet this criterion, he said.

Within the already-less-healthy VA population, some experts said, Al-Aly’s infected groups probably skew toward more serious Covid-19 cases. That’s because people with asymptomatic or mild cases are much less likely to visit a doctor, who would then document the positive result in the patient’s electronic record. The effect would have become increasingly pronounced as time wore on and people developed immunity and started testing at home, said Makam. He pointed to a VA study that looked at the risk of organ damage associated with reinfection. People with multiple Covid infections documented in their health records probably had relatively more severe courses of illness, he said. This doesn’t mean that the average person who gets reinfected and can manage their illness at home is at heightened risk of organ damage.

(The study, published in Nature Medicine, doesn’t mention this as a limitation, though it does suggest that bias could run in the opposite direction: If people with Covid-19 don’t get tested, and if they are at heightened risk of bad outcomes, then they could make the uninfected group look sicker than it actually is.)

Some experts also raised concerns that the VA St. Louis team has worked with data in ways that, from the outside, don’t clearly map onto established statistical practices.

In his email, Lipsitch raised questions about the group’s use of negative controls, a statistical technique that can help a researcher determine whether any associations — for example, an association between a Covid-19 infection and smell loss — are causally linked.

In an influential 2010 paper , Lipsitch and his colleagues proposed that negative controls should be routinely deployed in epidemiological studies. Applied to the study of long Covid, one type of negative control, called a negative outcome control, might involve identifying health conditions that are highly unlikely to be caused by the infection: accidental injuries, for example, or scarring. If an infection were found to be associated with one or more of these unrelated conditions, then this would suggest that some other variable — something other than the Covid-19 infection — is influencing the study’s results.

In order for this technique to work, said Lipsitch, researchers need to define their negative outcome controls before they conduct their analysis, and then report all the findings. The VA St. Louis’ first paper used neoplasms — a medical term for tumor — as a negative outcome control, but in the preprint , neoplasms were not treated as a negative control; rather, they were treated as an ordinary outcome. “There are also issues about how the negative outcome controls were chosen in subsequent papers,” Lipsitch wrote to Undark. The negative outcome controls differ across studies, he said, and it’s not clear why.

Some of this is difficult to parse, Lipsitch said, because the study’s methods are not clearly explained. “I think this is a case where peer review didn’t do its full job,” he said. “Because part of what peer review should do is to ensure that people with expertise in the field, ideally can reproduce, but at least can understand — in detail — what was done and make a judgment of how valid it was. And in this case, in its wisdom, Nature decided to let through a series of papers that describe their methods in such vague terms that it’s really hard to know what was done.”

Hviid also noted that the VA team changes its negative controls, along with its comparison groups, from study to study. “It’s a little bit weird,” said Hviid. Ideally, a research team would establish its analytical setup and then, whenever it wanted to add more data, the team would rerun the analysis using the same design. “I’m not saying that they’re intentionally fraudulent,” Hviid added, “but you’ve really got to be careful as a researcher if you’re sitting and running a lot of different analyses.”

The VA St. Louis team also used different approaches — including different weighting methods and a regression adjustment — to make its Covid and non-Covid groups comparable.

There might have been valid reasons for a research team to make such changes, experts told Undark. Peer reviewers might have requested them, for example. When asked about this by email, however, Al-Aly did not provide a rationale.

Undark also shared many of these concerns in a detailed email to Nature, whose portfolio journals published nine of the VA St. Louis’ long Covid studies. In response, Isobel Lisowski, a communications officer for Springer Nature Group, forwarded a statement on behalf of Nature Portfolio, which she asked to be attributed to Magdalena Skipper, editor-in-chief of Nature: “Our journals are editorially independent of each other, and each paper is assessed and peer reviewed independently based on its own individual merits. At all times our commitment is to ensure the accuracy of the scientific record and, if concerns are raised with us directly, we look into them carefully.”

The statement further noted that the VA St. Louis papers used several approaches to test the robustness of the findings, and that a  reporting summary  was published with each paper to increase transparency.

The BMJ, which published the VA St. Louis’ paper on mental health outcomes, published notes from the peer review. The reviewers did not raise the topic of negative controls. The VA St. Louis team did indicate that it was building additional cohorts to address reviewers’ concerns about possible bias in the study design.

Al-Aly is not unaware of the criticism. “I love these questions,” he said, wrapping up the first interview with Undark, during which he discussed his research as well as its possible limitations.

In conversation, Al-Aly is warm and funny, peppering his sentences with colorful idioms and playful hyperbole. (“You could test your cat if you wanted to. You can test your dog,” he said, recalling how Americans initially went all-in on at-home Covid testing.) He’s also willing to brawl, at times suggesting that many of his critics lack the expertise to evaluate his work or produce good research of their own. “We get a lot these newbies. They want to do studies,” he said. But their work sometimes contains what he characterized as “sophomoric mistakes.”

One example, in his view: the 2023 Israeli study of people with mild symptoms, which was published in the BMJ. “Do me a favor and look at their Figure 7,” said Al-Aly, off the top of his head, when asked about the paper.

Al-Aly pulled up the study on screen. Figure 7 shows that the vaccinated individuals in the study were at a higher risk for memory problems than the unvaccinated. The most plausible explanation, said Al-Aly, is that the researchers haven’t fully accounted for bias in their dataset. Further, he said, the study seems to assume that if a diagnostic code stops appearing in a patient’s medical record, this means the condition has resolved. In reality, said Al-Aly, “it’s very hard to document the resolution of symptoms in EHR.”

(In an email to Undark, a study co-author, Maytal Bivas-Benita, said that the memory finding wasn’t statistically significant. She added that her group’s findings are supported by a more recent Israeli study , which found a return to baseline in medication use and health care costs in non-hospitalized Covid-19 patients.)

Al-Aly was also critical of the study from Hviid’s team. Their control group, he suggested, consists of people who tested negative. The distinction matters because during the pandemic people with worse baseline health tended to test more frequently. A cancer patient needing chemotherapy in 2020, for example, would first need a negative Covid test. “When you compare sick people to sick people, you’re not going to find big differences,” said Al-Aly.

Speaking about the Danish study, Al-Aly said, “it’s not unreasonable to even call it deeply or fundamentally flawed.”

(“Clearly he has not read the paper very carefully,” said Hviid. His team’s control group included everyone without a positive test. While they did perform an additional analysis with a test-negative control group, Hviid said, it yielded the same results. )

<small”>Ziyad Al-Aly, who holds positions at Washington University in St. Louis and at the Veterans Affairs St. Louis Health Care System, is not unaware of the criticism surrounding his research. He’s also willing to brawl, at times suggesting that many of his critics lack the expertise to evaluate his work or produce good research of their own. Visual: Mary-Dale Amison/VA

According to Al-Aly, VA samples can speak to the broader population. While it’s true that VA demographics don’t perfectly mirror the rest of the U.S., it’s reductionist to dismiss the findings on these grounds, he said. The average age of VA patients is about 60, but this figure represents a large distribution, said Al-Aly. And while women are about 10 percent of the VA’s population, this can translate to more than 600,000 people in a VA study. “We can fill 10 — 10! — Taylor Swift stadiums” with women, he said, which makes it possible to look for sex differences in their findings.

He also said they adjusted for differences in testing and access to testing over time. This would substantially reduce any bias if it existed, said Al-Aly. (The VA team adjusted for “a huge list of confounders,” said Morris, when commenting on the study of neurological and psychiatric outcomes.) “But having said that,” said Al-Aly, now speaking specifically about his group’s reinfection study, “it’s not unreasonable also to interpret the study, ‘these are the results, and the results really reflect the people who actually tested.’”

Nonetheless, Al-Aly said, knowledge from VA studies can be applied to the general population.

Speaking with Undark, Eric Topol pointed to a May Substack post that he co-authored with Al-Aly. It highlighted a number of studies that he described as aligning with the VA research. One was an EHR-based study from Italy, which found that people infected with Covid-19 had elevated rates of cardiovascular problems even three years after infection. (The study did not distinguish between Covid-19 patients who were hospitalized vs. not hospitalized.) The post also described a longitudinal study of patients who were hospitalized with Covid-19 in Wuhan, China. Three years after their initial infection, more than half reported at least one symptom, most of which were mild to moderate.

Long Covid, said Topol, is “prevalent. It doesn’t go away normally. There are some people that are lucky that they fully recover, but most kind of limp along.”

Like Topol, Al-Aly also said that long Covid recovery is rare, particularly among people who have significant post-exertional malaise or fatigue that lasts more than several months. Clinicians are not seeing recovery in these patients, he said.

Although Al-Aly was one of many co-authors on the Global Burden of Disease’s systematic review that found most people do recover, he said that the findings need to be interpreted with caution. The review’s primary goal was to track symptoms, not recovery; and even then, the study did not track all long Covid symptoms. Additionally, the review drew from a wide variety of studies — some based on surveys, others on clinical assessments, and yet others on information in databases. This is not the best way to assess recovery, he said, because long Covid symptoms sometimes come and go. A person may have brain fog that lets up for a while, only to return later. The best way to assess for recovery, said Al-Aly, is to follow people over time, checking in every three months or so.

(“That is an interesting point of view,” Vos wrote after Undark shared some of these concerns with him. “I think we had enough studies in our 2022 paper to reject the hypothesis of no recovery.” He added that his research team is currently working on an updated analysis: “It does look like there will be a small subset of people who remain symptomatic years after infection.”)

Later, when asked by email about specific critiques involving negative controls, Al-Aly described them as “grossly unfair.”

In response to a separate email asking about the different statistical approaches used to make his Covid and non-Covid groups comparable, Al-Aly pointed back to the Israeli study, the Danish study, and the Global Burden of Disease study: “We are criticized for using negative controls,” he wrote. These other studies “don’t use any means of quality control. Quite ridiculous that you criticize us for doing the right thing and elevating the rigor of the work.”

The scientific debate over long Covid has unfolded amid undeniable human suffering. Across the country, clinics have reported handling an influx of cases since 2020. Previously healthy individuals may suddenly find they need to sleep 18 hours a day. They may struggle with brain fog and breathlessness. Many people have had to scale back on work or quit their jobs entirely. Specialized care is often difficult to access , particularly for Black and Latino patients.

A post-viral condition can steal your whole life, a patient advocate told Undark. In severe, or even moderate cases, “you’re stuck in bed all day, you lose your friends, you lose a lot of your family, you lose your jobs, you lose your aspirations for life. If you wanted to have kids, if you wanted to get into a relationship, if you wanted to start a business, if you wanted to continue a hobby — all of that is gone.

“You’re just kind of suspended in life and dependent on the outside world to come to your rescue,” the patient advocate continued.

Those patients often find themselves facing skepticism from people who do not believe the condition is real — including, in some cases, their own doctors. And they are navigating symptoms at a time of intense political polarization over the implications of Covid-19.

The idea that long Covid is widespread, and that its numbers are growing, can be comforting for long Covid sufferers, said the patient advocate, who spoke on condition of anonymity in order to avoid blowback from within the patient community, which the advocate said, views Al-Aly as a god-like figure.

“He is beloved by patients. And I’ll tell you why I think he’s beloved by patients: because patients feel left to rot and die, and he has told them what I think some people interpret as a scary story, which is ‘long Covid is rampant. Everyone’s going to get long Covid. It’s going to disable the population,’” the advocate said. “To a patient, this is not a scary story. To a patient, this is actually a very hopeful story because everyone’s going to get sick; they’re going to have to help me.”

But the advocate expressed deep misgivings about promoting exaggerated views of the number of people at risk of developing long Covid. Such views won’t “help to have you taken seriously by skeptical people.”

For now, U.S. public health authorities — drawing on the research of Al-Aly and his colleagues — have continued to trend toward the broadest possible definition of long Covid.

The recent National Academies of Sciences, Engineering, and Medicine report recommended a new definition of long Covid for the U.S. government and health care system. The final result looks remarkably similar to Al-Aly’s description of the disease: Long Covid can be mild to severe, the report states, and it may include just one symptom or a single new diagnosis that develops after a SARS-CoV-2 infection and persists for at least three months.

In practice, this means that if a person has a mild case of Covid — say a cough and fatigue lasting one week — and then develops a chronic condition like lupus six weeks later, this new lupus patient could also be diagnosed with long Covid. “Clinicians must exercise their judgment and rely on evidence in reaching a diagnosis in any individual patient,” wrote Harvey Fineberg, a prominent public health expert and chair of the report, in an email to Undark.

Fineberg pointed to electronic health record data suggesting a large jump in rates of lupus onset after a Covid-19 case. Given that, he wrote, “a clinician would be wrong some of the time, but they would be more often wrong if [they] failed to ascribe the condition to long Covid.”

The long Covid diagnosis, Fineberg added, could help patients understand where the lupus came from, and perhaps in the future suggest treatments.

Public health expert Harvey Fineberg chaired a recent report which offered a new definition of long Covid. Fineberg stressed that “clinicians must exercise their judgment” in reaching a diagnosis.

But Putman, the Wisconsin rheumatologist, who treats lupus patients, noted that not all studies have found such a strong connection between an infection and lupus. He pointed to 2023 paper that actually found a protective effect of Covid-19 against lupus. “Do I believe that? No,” he wrote in an email. The real issue is “the data in this area are all very uncertain and often contradictory.” It’s implausible, he added, that the majority of new lupus diagnoses have been driven by Covid-19 infections. If this were the case, “we would expect a dramatic increase in the yearly rate of new lupus diagnoses. As far as I can tell, the incidence is more or less stable.”

Putman added that it would be difficult to run an effective clinical trial using a broad definition. The study participants would likely have multiple underlying pathologies, he said, that don’t all respond to the same treatment.

This new definition may also undermine the real and profound suffering experienced by some people with post-viral illness, said Leonard Jason, a psychology professor at DePaul University who has long studied ME/CFS, a severe condition marked by life-altering fatigue. “If a person has trivial pain in the toe for 3 months following Covid infection, with no negative consequences to the person’s functioning or quality of life, that person would still be eligible for a long Covid diagnosis,” he wrote in a recent opinion piece for Medpage Today. It’s a mistake to ignore symptom frequency and severity, he wrote.

The report recommended that the definition should be reviewed and possibly updated in no more than three years’ time, as the science continues to evolve.

“During the pandemic, the quality of research went down,” said Anders Hviid during a May Zoom call. “I think some scientists and probably also journal editors became a little one-sided or blind. Maybe it was because it became so polarized. So, people were either in one camp or the other.” There’s no question, he continued, that harmful symptoms can follow Covid-19 infections. But conversations about the frequency of those symptoms seemed out of touch, he suggested, particularly as time passed and the risk of developing long Covid declined as people acquired immunity.

Makam, in San Francisco, meanwhile, has spent years studying long-term health outcomes of people with prolonged serious illnesses. He worries about the consequences of having a poor case definition for long Covid. “How can you study a disease if you’re defining your illness very, very broadly, including a lot of different pathologies into this one disease syndrome?” He was blunt in his assessment of the work coming out of the VA St. Louis. “We’re going to look back and that entire line of work is going to be wrong. Like very wrong.”

Al-Aly’s third interview with Undark took place on May 30, the day Nature Medicine published his three-year follow-up study of patients with a documented Covid-19 infection in 2020. He had been up late the night before, putting together a thread on X, the platform formerly known as Twitter, with key points. It wasn’t all bad news, he wrote. Over time, people in the infected group became significantly less likely to die or develop new onset disease. Yet even three years out, those with mild infections remained at increased risk for some new onset symptoms.

He also expressed frustration with some of the criticism that has come his way, particularly on social media . “Good scientific criticism can sharpen the focus of the inquiry and make it better,” he said. But all too often, the critiques don’t serve any clear function and may even feed into denialism. “A lot of people feel sick and tired of this pandemic and want to move on, which is totally, totally understandable. Like, who doesn’t understand that? Who doesn’t sympathize with that?” Still, he said, the fact remains that many people need help, and he plans to help them — his detractors be damned.

“To the chagrin of the critics, we’re going to keep moving the ball forward,” Al-Aly said. If that irritates people, they’ll just have to get used to it, he added. “We’re working day and night to solve this problem.”

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Though I haven’t read everything, IMO, one of the difficulties with long Covid is that there are, quite probably, many different long Covid diseases each one with different symptoms, disease markers etc. This might depend for instance on which parts of the body/brain the virus spread but compound that with different health backgrounds etc. This is not to say common or frequent markers cannot be found but it makes difficult even to define the group of diseases.

Yes, exactly.

I posed the same.

Lung fibrosis will not generate the same biomarkers as an autoimmune condition, and it may well be, in fact it does look like it, that even the autoimmune conditions triggered by COVID are not all the same.

Thanks, Yves, for posting this. And also for the shout out to ME/CFS, which I have had for decades now. Several thoughts in no particular order:

Sadly the belief that ME is psychological is far from dead. Just last week another young woman passed away after allegedly being treated in hospital as though her illness were her fault (as far as I can tell she fought for total parenteral nutrition but at some point gave up and opted to starve to death rather than continue to suffer–even when, at the 11th hour, TPN was authorized).

And then there was the NIH intramural study, which I gather is a bit of a Frankenstein’s Monster in that it has some useful data but also prominently features, for no reason patients can understand, “exercise preference” as a prominent concept. Patients have not been happy. There may be an inquest. If I were in the long covid community I would be very concerned that the same shitty researchers behind “exercise preference” and the PACE trial would bring their snake oil over to Long Covid Town.

Regarding Biomarkers: Apparently there are several promising ones for ME. None are widely used or accepted though. The one exception may be the two day CPET, where a patient intentionally makes themself worse, potentially permanently, in order to prove that their reactiin to exercise is different from someone who merely had not exercised much.

I am a particular fan of Ron Davis’ nano needle as a potential fiagnostic tool. Unfortunately, his application for funding was denied on some strange grounds like, iirc, that his son had ME so therefore he would be biased. As far as I have heard it remains a potentially promising biomarker, even if it might not rule out other some other causes of fatigue which would, I assume, need to be ruled out separately.

I mention all of this partly because these biomarkers might also help with long covid and I am not aware of anyone looking at that. And I can’t see why we shouldn’t.

On definitions: As the article said, the tug of war here is between patients and their advocates who feel that one disabling symptom should be enough to get approved for disability, and researchers who get frustrated by data made unreliable by the inclusion of a lot of people who technically fit the definition but whose illness might be entirely different (ie untreated b12 deficiency or iron deficiency). Both concerns are valid, and it makes me think that perhaps we should have a broader legal definition and a more narrow one sometimes used in research

One final thought or question: Of all the studies mentioned the Danish study did sound like it might potentially have the least bias in terms of counting covid infections, since they tested everyone who went out in public. Al-Aly dismissed it but didn’t provide any details. I wonder what his critique is?

Several things to note here:

1) Long COVID and SARS.

Once again one of the foundational sins of the pandemic is manifesting itself. Thousands of words and not a single mention of the original SARS outbreaks in 2003. It’s as if it never existed or it had nothing to do with COVID. When it is in fact a closely related virus, with largely the same properties. Just much more severe.

Had what happened in 2003 not been completely ignored, there would be very little controversy about LongCOVID. In fact everyone would have been quite certain LongCOVID would be a massive problem on January 1st 2020, i.e. the moment it was announced this was another SARS virus.

Because SARS patients back then developed something very similar to COVID, just at much higher rates and with on average greater severity. And they mostly never recovered.

2) This incredible howler:

“It’s just difficult to imagine that a simple respiratory virus could be so detrimental to all organ systems at a population-level scale,” said Hviid. One’s intuition can always be wrong, he added, but given that other respiratory infections, including influenza, do not exact such a massive toll, skepticism seemed like the right starting point: “You should question, ‘Can that be right?’”

Of course, the answer to this puzzle is that this isn’t a simple respiratory virus. It is a systemic infection.

And had that “expert” done his homework about SARS viruses, he would have known that. But he still hasn’t five years into this…

3) Biomarkers.

Because it is a systemic virus, the mechanisms behind LongCOVID are very diverse. So it is not unexpected that there aren’t consistent biomarkers. You have direct cytopathic damage to various organs — lungs, obviously, but also hearts, kidneys, etc. You also have more indirect damage through other mechanisms (looks like that is what happens to neurons in the brain). And you have general immune dysregulation. And most people only suffer some of these. Clear common biomarkers are most straightforwardly derived from the immune dysregulation. But again, far from everyone gets it the same.

4) Conflicts of interest.

Where do we start here…

Back in 2020 there were still some people in the public health/epidemiological/virological/medical communities that still had integrity and wanted to solve this problem. Five years later their number has dwindled greatly. The big names know what the political mandate is and what lines have to be followed, if the inflow of grants and awards is to continue. So they are not going to go out publicly telling everyone how we just infected everyone several times and are strongly committed to infecting everyone endlessly with a virus that causes permanent damage to a substantial proportion of people on each round. That would be as clear example of a monstrous crime against humanity as there has ever been, right? But out political elite consists of pure and innocent people who would never do such a thing, right…

All of this is well stated as usual, but point 2) really gives the game away here. Calling SARS/Covid a “simple respiratory virus” immediately discredits the “expert” in question and shows that said expert is as susceptible to the politicisation of the problem as the vast sea of normies. It is no more a “simple respiratory virus” than measles.

Put another way, if you had asked a specialist in a relevant field in, say, the first half of 2019: “Was SARS/is MERS a ‘simple respiratory virus’ there were only two possible answers to that question: “no, obviously not” or “I don’t know”. If one answered the latter, they could acquaint themselves with some of the literature in about a day and come back answering the former.

(Some hypothesised early on that after ~immunity~ that SARS2 would become a mere simple respiratory infection, sometimes with reference to OC43, hypothesised to have become a common cold virus after causing a pandemic in the late 19th century. Evidence for this historically and contemporarily remains thin-to-non-existent.)

this speaks to GM’s point 1), the total ignoring of the SARS1 literature in this and almost all similar articles, which, crucially, was not a politicised disease. SARS2 is closely related to SARS1.

The other point is how this article totally ignores the many studies demonstrating observed pathological damage in SARS2 survivors – not all, but enough to be a serious problem. These have been shared repeatedly here. The most striking is brain injury. There’s also the lung damage question – ie recall the case of the 50-something tech billionaire who injects himself with unicorn piss or whatever because he’s afraid of aging having his lungs shredded after a “mild” omicron infection. He only knew this, of course, because he’s rich enough to have advanced medical imaging on tap. That the article focuses on Al-Ahly’s more epidemiologically-oriented studies while ignoring the immense body of complementary literature on the specific mechanisms of potential harm of this disease is clearly a deliberate tactic.

Finally, briefly, the article leans on “muh immunity” gospel. a couple of anointed experts toss out the “this will become less of problem going forward because immunity” which is obviously just made up, and in fact ignores a specific Al-Ahly study showing increased risk of LC with subsequent infections using real world data.

The purpose of the article is to prime Undark readers, using a fairly thin veneer of journalistic impartiality, to react with either “aha! bullshit!” or, “probably nothing to worry about” the next time new Al-Ahly research is publicised. This isn’t to say he’s infallible (and by the way, quoting an anonymous long covid patient to try and stitch Al-Ahly up with “the community treats this guy like some kind of god figure!” is so pathetically transparent), but nor is he the first and last word on the scale, scope and specifics of this problem which is very obviously a very big one.

How can an article this exhaustive about long covid never mention the possibility that the Covid vaccines may play a role in it as the vaccine makes the body produce a longer lasting synthetic spike protein? The spike protein being recognized as the main pathogenic feature of the covid infection. Also there is the fact that the nanoparticle coatings of the synthetic mRNA delivered by the vaccine can also cause distress in the body.

Because large-scale studies consistently shows that getting vaccinated reduces the incidence of Long Covid.

Moreover, vaccine uptake has fallen off a cliff while Long Covid prevalence continues to rise.

Moreover, data from countries that had formerly contained and eliminated the virus and therefore had relatively distinct periods of mass vaccination followed by mass infection, show increased prevalence of long covid and other noticeable population-wide indicators of adverse health correlating strongly with the period of mass infection, and not with mass vaccination. Like, at all. NZ shows this most clearly. Australia too to a lesser extent (greater overlap here between mass vaccination and mass infection in the 2nd half of 2021 in some states.

Moreover, there were trials of the vaccines before they were deployed. These were relatively rapid, due to the acute nature of the crisis, but the fact remains that there was no report of anything like a statistically significant emergence of a long covid-like syndrome in the trial data. There were reports of vaccine harm in VAERS once the vaccine was deployed, but on top of all VAERS’ usual limitations, the data is fairy useless as it is confounded with basically unrestrained mass infection in a country where the disease and vaccine were both hopelessly politicised, including among MDs. On the other hand, in Australia, as soon as AstraZeneca was showing a slightly discernible increased risk of clotting (which is one manifestation of LC) in certain age groups after it was deployed, its access was greatly throttled (and it is of course no longer available).

Vaccines are not causing this problem, and “but teh spike protein!!”, while it is certainly, shall we say, a talking point is a meagre and unpersuasive argument to the contrary. This blog primed me in 2020 to entertain the possibility that the vaccine would be Literal Poison as a consequence of a rush job from some of the most untrustworthy companies on the planet. It’s not. That’s unambiguously clear.

The doomed-to-failure vaccine strategy, however, was the wrong one, and has had disastrous consequences since early 2020, vaccines being both unnecessary and insufficient to solve the problem of SARS-CoV-2. Selling the covid vaccines as on a par with the vaccines that changed the course of human history, in spite of the decades of literature showing poor performance of vaccines against coronaviruses, was, besides itself being a de facto anti-vax policy (although the out-and-proud covid anti-vaxxers, themselves being every bit the abject and inane conformists as the vax-and-done crowd, are too stupid to even begin to grasp this), an outrage that has been used to rationalise mass death and illness at an unconscionable scale, and redirect the electorate’s anger to the paltry and inept attempts of most states to reduce this burden of human suffering during the acute stage of the crisis. That all said, I have no regrets about being vaccinated and will readily get vaccinated again should the circumstances call for it (not bothering atm because NPIs have been extremely effective for me and there are no meaningfully up-to-date vaccines available so it’s not a particular priority for me at the moment).

Thanks for a very clear exposition of the issues.

It is of course possible that individuals can suffer from vaccine damage while the population as a whole benefits. I know at least one person who likely suffered vaccine damage. I was very sceptical at the time (I assumed that she had just got covid coincidentally with the vaccine and was suffering long covid), but the more I find out about her case the more likely it is to me that she is one example of vaccine damage. But as you and Yves have pointed out, study after study indicates that at a population level, vaccines do provide significant protection/mitigation of long Covid.

What is infuriating of course is that it seems that all public health authorities are just focusing on giving vaccines seasonally to the vulnerable, instead of systematically investigating how they can be used (along with all the other mitigations we know about), to minimise the damage covid is doing to us all.

Just to add one point on SARS1. Its not just the long covid potential of the virus that was memory holed. There were also plenty of studies at the time of SARS1 that strongly pointed to it being an airborne virus. From memory, there was a very good study from Hong Kong that proved that it had moved through an apartment building via the ventilation/sewerage system. This was, of course, completely forgotten about by 2020.

Thanks for that very clear summary of quite probable and justifiable reality.

“It’s just difficult to imagine that a simple respiratory virus could be so detrimental to all organ systems at a population-level scale,” said Hviid.

In my view, this is the problem – SARS-COV-2 is not a respiratory virus. It is a virus that attacks the vasculature and can damage blood vessels throughout the body and so affect every organ system. This will account for the myriad symptoms of long covid. Furthermore, the damage might be progressive and symptoms might not occur rapidly, but only emerge as *new* symptoms some period of time after an apparent recovery from the infection.There are now very many reports on the endothelial dysfunction and thrombotic effects of Covid-19. (For example: Xu et al., 2022 “Endothelial dysfunction in COVID-19: an overview of evidence, biomarkers, mechanisms and potential therapies”) The most frequent route of ingress is via the respiratory system causing damage to the hyperfine vascularization of the lungs. Thus, respiratory symptoms are common and this has lead, in part, to the notion of it being a respiratory virus. The other reason is likely it being a coronavirus – the same virus family that common cold viruses belong to. But, barking up the respiratory virus tree is not helpful because it drags along with it strong biases about what respiratory viruses can and cannot do as exemplified by Hviid.

I had an asymptomatic wild type infection somewhere in January 2020(!). At the time I was healthy, ran 25 km a week and lifted weights regularly. By the end of 2020 I could no longer run or lift weights without getting post exertional malaise (no shortness of breath, no sore muscles, but 6 to 48 hours after exertion appear chest pains, fatigue, impaired balance, brain fog and this can take more than 3 weeks of rest to abate). I had also experienced many different symptoms that fluctuated in severity and onset. These included a (permanent?) loss of sensation on the soles of my feet (small fiber neuropathy), tinnitus that might last for several weeks and then disappear only to reappear a month or two later, impaired olfaction, chest pains (the cardiologist could not see any problem), brain fog (memory problems, cognitive problems), impaired balance, excessively prominent veins, “covid toes” due to pooling of the blood in the feet, hair loss, sleep difficulties, dyslipidemia (all other blood tests normal), microclots confirmed with fluorescence spectroscopy, joint pains, and there are more. New symptoms emerge out of nowhere. Others seem to disappear. Fortunately I am not bedridden as some others are and I can still manage to look after myself. But I have noticed a steady decline in overall health over the past 4 years of long covid. I have also never tested positive for SARS-COV-2 (PCR for nucleocapsid, nasal swab for spike protein by pharmacist, numerous rapid antibody tests for spike protein) yet there is no other reasonable way to account for the symptom onset and range other than ascribing it to Covid-19.

If, as I understand current thought, Covid is a vascular disease that can cause damage throughout the body, alters the immune system, has been demonstrated to invade the brain, and can lay dormant for years before rampaging a la HIV, then the manifested harms will be legion and many may already be baked in. At least medical professionals are masking and building ventilation has been improved (sarcasm alert). I hope research leads to better treatment for those suffering today from Covid damage and others that will be joining their ranks. While we still have enough people with most of their cognitive functions intact.

I think Yves is too kind. I don’t see mere arrogance, I see obfuscation.

We’re drowning in strikingly various evidence for persistent organic disease(s) post-covid, and have been since early in the pandemic. In this context one should anticipate that sorting out correlations and causes will be difficult, even bewildering. Epidemiologists using this as an excuse to ask “Is it real though?” are beneath contempt.

this is an exceptionally well written article. Nuanced and insightful. It speaks to the enormous challenges of even good people doing quality research on a nebulous illness. Just the matter of disease definition: it isn’t so much who is right or wrong, but what gets missed depending on how wide or narrow you define the illness.

Re: it seems to be unduly inclined to take the point of view that there must be biomarkers, a well-understood pathological process, and/or a tidier set of symptoms You have hit the nail on the head Yves. Conventional MDs simply can not seem to grasp gray areas- if there is not a well known clear cut test with a binary positive/negative, or high/low, pointing clearly to a straightforward diagnosis, they refuse to acknowledge it. CFS/ME is correlated with high IgG antibodies to EBV, CMV, HHV-6. But because almost everyone carries a viral load, and not everyone ends up with chronic fatigue, most doctors refuse to think those results are significant when a patient is symptomatic. Despite the fact that when these patients are treated for these viruses, it does indeed improve their symptoms. And yes there are pubmed studies out there pointing out that even without IgM antibodies to these herpes family viruses, IgG load can causes symptoms and should be addressed (but for whatever reason these types of studies get ignored).

And we know now of course, that Covid can also reactivate viruses such as EBV and cause chronic fatigue and/or fibromyalgia symptoms even in people who never had these issues before. As Ignacio mentioned, Covid will manifest in different ways in different people. But this doesn’t fit into the cookie cutter paradigm of the allopathic world where x disease means you get x drug and this works for all patients with x disease.

A patient told me she waited for months to get into the long covid clinic and has seen specialists there for about a year but feels they don’t communicate well and she is getting confused between all the medications and supplements she is now taking. Her latest inquiry was about how her long covid doc feels she could try an SSRI since that seems to help some of the other long covid patients. Her psychiatrist said well you are already on another anti-depressant, starting an SSRI can cause more side effects, why don’t you take St John’s Wort instead. She asked me what I thought: 1. Your long covid doc seems like they are shooting in the dark but sure we can try some serotonin support 2. I’m very surprised your psychiatrist recommended St John’s Wort. Many herb-drug interactoins are overblown but this is a very well known and legitimate one and considering how many pharmaceuticals you are on, this is not the best idea. 3. We can add in cofactors and precursors to serotonin to your treatment plan that will not interfere with your medications instead if you prefer.

She also got the recommendation from either her PCP or long covid doctor to get a Covid booster. She had a severe reaction to the mRNA vaccine in the past- I’m sure you can guess which one they had her get, not even bothering to mention any alternatives like Novavax. And all of her symptoms flared badly for weeks. It is frustrating to see “experts” in “expertise” clinics bumble around and I feel for these patients. They are not getting the guidance and treatment they deserve.

Looks to me like “don’t catch Covid” remains priority #1 for those looking to avoid disability or worse.

Thanks much for this piece Yves. The gaslighting from the medical community is infuriating.

According to some it was designed to do just that, ie “gain of function”.

My neighbor’s son-in-law and I both have long COVID. As he put it, “there’s your life before LC and your life after LC”. Others, like the guy who delivers our propane, says that he now becomes exhausted after half a days work. The Facebook LC support group is full of very sad stories – many people much younger than myself are completely debilitated, at least I can still get out of the house and do things. Many of these people still have to work.

My local MD has referred me to a physician in Seattle at the University of WA hospital who is treating LC patients and running a study. I’m wondering if it will be worth the trouble of driving down there (60 miles of heavy traffic) to see him but I may give it a try at least once and see what he has to say.

For remedies, I am trying all kinds of things – Chinese herbs, acupuncture, supplements etc. Currently I am trying nicotine patches as there is a very small study that indicates that nicotine may bind to the same cell receptors as coronvirus spike proteins.

https://europepmc.org/article/PPR/PPR552490?javascript_support=no

I’ve only been on them for 4 days but it seems to help.

Even before my husband and I got Covid together in February 2021 — we were sick at the same time for six whole weeks — and subsequently Long Covid up until now, I got solid information and analysis from Dr. Roger Seheult on MedCram. He is a pulmonologist and medical researcher that has been treating Covid patients since the beginning of the pandemic, and very soon he made it clear this is a systemic illness that causes significant and lasting vascular and immunological damage on the body.

While some individuals in the scientific community keep debating the merits and nuances of a Long Covid diagnosis, etc., as they fight for grants and notoriety amongst themselves, patients like my husband and myself deal with the day to day realities of this condition. We are lucky to have access to an excellent Long Covid program in NY (at Mt. Sinai) where we see doctors that treat us in validating ways, working with us as a team. We are also lucky to be able to compare our experiences with one another and observe our progression, and help each other manage our symptoms with love and compassion. The human aspect of Long Covid is extremely important to deal with it.

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Where Harris stands on Israel, abortion, climate change, education and the economy

[Editor's note: An earlier version of this story misstated Harris' proposed 2019 climate plan investment levels. The correct estimate is nearly seven times more than Biden's current proposal.]

Vice President Kamala Harris has emerged as the Democratic party’s presidential frontrunner after Joe Biden dropped his reelection bid Sunday.

Most Democrats have backed Harris, who announced her 2024 campaign for president shortly after Biden penned a letter explaining his decision to exit the 2024 race. Depending on who you ask, Harris is viewed as a moderate or a progressive reformer.

A former prosecutor, Harris was elected San Francisco’s district attorney with a “tough on crime” message in 2003 and worked in that role for seven years. She became the state’s attorney general in 2011 and served until 2017, when she was elected to represent California in the U.S. Senate.

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More: Election 2024 live updates: Endorsements rush in for Harris; Trump attacks begin

Harris launched her own unsuccessful presidential campaign at a rally in her hometown of Oakland, California in 2019. She dropped her bid for the White House and joined President Joe Biden’s ticket in August the following year. In 2021, she was sworn in as vice president.

Decades in the public spotlight and on the public record, here is what we know about where Harris stands on key issues:

Foreign Policy

As Biden’s second-in-command, Harris has largely stood behind his foreign policy positions, but there are signs she could be tougher on Israel over the war in Gaza than the president.

Harris has not given reason to believe she will deviate much from Biden on issues relating to China , for example. She is also unlikely to sway from supporting Ukraine. Harris said earlier this year that Russia has committed “crimes against humanity” in Ukraine over the last two years.

Harris has not directly opposed Biden’s staunch support for Israel, but has expressed sympathy for the more than 38,000 Palestinian lives lost during the conflict. She was one of the first high-profile members of his administration to call for an immediate temporary cease-fire in March. She acknowledged the “immense scale of suffering” in Gaza and said the Israel-Hamas war is a “humanitarian catastrophe” for innocent civilians.

Harris’ support for women’s access to abortions has been a focal point of her tenure as the country’s first female vice president. She embarked on a nationwide Reproductive Freedoms Tour earlier this year to draw attention to attacks on abortion access following the Dobbs decision . She attended her first stop in Wisconsin on Jan. 22, the 51st anniversary of Roe v. Wade .

Harris proposed federal protections that would limit state abortion restrictions during her first presidential campaign. Under her proposal, states would need to clear laws regulating abortion with the Department of Justice, which would need to confirm they are constitutional before taking effect, she explained in 2019 .

“How dare these elected leaders believe they are in a better position to tell women what they need, to tell women what is in their best interest?” Harris asked during a visit to a Minnesota Planned Parenthood clinic in March. “We have to be a nation that trusts women.”

Harris has traveled on an Economic Opportunity Tour this summer to defend the Biden administration’s economic policy and attack former President Donald Trump’s economic agenda.

While on tour, she touted legislation passed during Biden’s time in office, including the American Rescue Plan and Inflation Reduction Act . Harris has tried to emphasize that wage increases have outpaced inflation since the pandemic and made the case that Trump has plans to give more tax cuts to the rich.

“Donald Trump gave tax cuts to billionaires,” she said in a June social media post . “President Joe Biden and I are investing in the middle class and making sure billionaires and big corporations pay their fair share.”

The vice president has made clear that climate change is a key issue a Harris administration would seek to address.

While running for president in 2019, she proposed a climate plan with a $10 trillion price tag — nearly seven times more than the $1.6 trillion Biden has invested in addressing the issue. She also called for a ban on fracking.

As a senator, she co-sponsored the Green New Deal , which called for a dramatic increase in the production of renewable fuels, including wind, solar, and hydropower sources. The 10-year mobilization plan pushed for a transition to energy systems less reliant on generating greenhouse gases, which are the primary contributors to climate change.

Harris has been an advocate inside the Biden administration pushing for the president to forgive student loan debt , which became a staple of his domestic policy agenda.

As a senator, she co-sponsored Vermont Sen. Bernie Sanders’ legislation to make two-year college free for all students and waive tuition for middle-class students attending four-year public universities.

At a Pride Month event last year, she criticized Florida’s 2022 “Don’t Say Gay” law banning educators from discussing sexual orientation and gender identity in elementary and middle school classrooms. Shortly after she announced her presidential campaign Sunday, the American Federation of Teachers endorsed Harris.

Rachel Barber is a 2024 election fellow at USA TODAY, focusing on politics and education. Follow her on X, formerly Twitter, at @rachelbarber_

Kamala Harris: Everything you need to know

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Kamala Harris’ life has been filled with milestones.

Her elementary school class in the 1970s was the second one to integrate Berkeley schools .

Harris was the first woman elected as San Francisco’s district attorney.

She was the first woman to be elected as California’s attorney general.

She was the first woman of color to be elected to the U.S. Senate from California.

She was first woman elected vice president of the United States.

Now, with President Biden announcing Sunday that he will step aside as the Democratic presidential nominee and endorsing Harris, she is close to becoming the party’s Democratic nominee for president.

The Times has been covering Harris extensively for two decades. Here is an overview of her story from our pages.

California roots

From Oakland to Canada and back, with inspiration from India

• Harris was born in Oakland to parents who had come to California to study at UC Berkeley. Her father, who has roots in Jamaica, was an economics professor; her mother, who had roots in India, was a cancer researcher. Harris spent several years as a child in Oakland and Berkeley, but after her parents divorced, she and her mother moved to Canada.
• Harris has spoken of her Indian grandfather as being a key force in her life, and of her interest in government. P.V. Gopalan was an Indian civil servant on assignment in an era of postcolonial ferment. As The Times reported, “Until his death in 1998, Gopalan remained from thousands of miles away a pen pal and guiding influence — accomplished, civic-minded, doting, playful — who helped kindle Harris’ interest in public service.”
• From seventh grade to the end of high school, Harris and her mother lived in Montreal and its Westmount neighborhood.

Harris earned her bachelor’s degree at Howard University in 1986.

• After graduating from the University of California Hastings College of Law in San Francisco, Harris passed the bar examination and worked her way up in the Alameda County and San Francisco County district attorney’s offices. Harris was San Francisco district attorney from 2004 to 2010.
• Harris started dating entertainment attorney Doug Emhoff and permanently relocated to Brentwood by the time they married in 2014.
• In 2016, Harris was elected to the U.S. Senate, leaving her California job to take office early in 2017.

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Political beginnings

A prosecutor with an ambition for Bay Area politics

• Harris got her start in Bay Area politics and law enforcement. She prosecuted murder, rape, assault and drug cases at the Alameda County district attorney’s office in Oakland from 1990 to 1998.
• San Francisco Dist. Atty. Terence Hallinan had hired Harris in 1998 to lead his career-criminal unit. She ended up running against him and winning in 2003. The campaign was bruising, with critics citing her relationship with San Francisco’s colorful and controversial Mayor Willie Brown. Her record as a prosecutor included some progressive policies but other ones that critics would later say were too “tough on crime.”

In 2010, Harris moved to statewide politics, defeating Republican Steve Cooley for attorney general.

• As attorney general, she started implicit-bias training for law enforcement, and as district attorney she launched a program that enabled first-time nonviolent offenders to get their charges dismissed if they finished job training. Critics have faulted her, though, for working in court to uphold California’s death penalty, despite her personal opposition, her threats to jail parents of chronically truant schoolchildren and flop flops.
• In 2016, The Times editorial board praised Harris for being willing to stand up for the little guy as attorney general. But it issued this warning: “Harris has at times seemed more focused on her political career than on the job she was elected to do. She has been too cautious and unwilling to stake out a position on controversial issues, even when her voice would have been valuable to the debate.”
• Harris gained national attention for her efforts to have courts overturn California’s ban on gay marriage and allow same-sex couples to legally marry.

Kamala Harris was shaped by the crucible of San Francisco politics

Jan. 21, 2019

Kamala Harris regrets California truancy law that led to arrest of some parents

April 17, 2019

California’s tough-on-crime past haunts Kamala Harris

Oct. 24, 2019

How Kamala Harris’ California career prepared her for the White House | Covering Kamala Harris

Jan. 19, 2021

Kamala Harris calls for same-sex marriages to resume ‘immediately’

June 26, 2013

National stage

Breaking barriers with a rise to Washington

• Her next move was the 2016 race to replace the retiring Barbara Boxer as U.S. senator. With Democrats dominant in California, it came down to a history-making battle between her and Southern California’s Loretta Sanchez. When Harris won, The Times declared that she tore “down a color barrier that has stood for as long as California statehood.”
• In 2019, she began her campaign for U.S. president. Early on she built strong momentum, drawing a crowd of roughly 20,000 to a lavish Oakland rally. She raised $1.5 million in just 24 hours. She boasted a string of endorsements from California politicians.
• But her campaign slowly sputtered. As The Times reported in March 2019, the fall “stems in part from Harris’ failure to present a compelling case for her candidacy beyond her background as a prosecutor, her buoyant personality and a deep contempt — shared by others in the contest — for President Trump.”
• In December, she suspended her campaign. The Times called it a “lackluster end to an initially soaring presidential bid premised on the California senator’s personal biography and prosecutorial acumen. Ultimately, her run foundered with a muddled purpose, campaign infighting and an inability to sustain support from vital Democratic voting blocs, particularly African Americans.”

• Biden locked in the nomination, but there was no guarantee he would pick her as his running mate. Some felt the Biden team was angry at her treatment of him during the campaign. But Biden ended up selecting Harris. The Times said at the time: “In many ways, Harris is a safe pick — broadly popular in the Democratic Party and well acquainted with the rigors of a national campaign. But her selection also carries symbolic heft in this moment when race relations are at top of mind for voters.”
• Harris held her own during her debate with Vice President Mike Pence and serving as an effective surrogate. The Times reported “Those who have spoken with Harris say she sees the changes — in style, in her approach to campaigning, in the faces surrounding her — worth the goals she now pursues: replacing Trump with Biden and becoming the first female vice president in history.”

Kamala Harris emerges as a 2020 front-runner, but is that a good thing?

Jan. 27, 2019

After dazzling debut, Kamala Harris falls from top of presidential pack

May 31, 2019

Kamala Harris’ bid for the Democratic nomination comes to an end

Dec. 3, 2019

After being her own boss, Kamala Harris embraces new role as Biden’s No. 2

Oct. 21, 2020

Kamala Harris makes history many times over as vice president-elect

Nov. 7, 2020

Kamala Harris, the first Black woman in her role, just broke a record held by an outspoken slaveholder

Dec. 5, 2023

Vice president

Struggling to find her footing in a big job

• Harris made history when she took office.
• But her term has been marked by successes and struggles.
• After her first year in office, The Times offered this assessment: “Harris has struggled to tell her own story, leaving others to fill the void. Conservative media have attacked her while mainstream outlets have published a string of stories about low morale and high staff turnover in her office. Like many vice presidents, Harris is learning how hard it is to define herself as a No. 2.
• She was handed a difficult assignment in those early months: Leading diplomatic efforts to curb migration from Central America. There were early controversies, such as when she told would-be immigrants not to come to the United States . As the immigration issue has become hot in the 2024 race, Harris faces tough questions about her role in Biden policies.
• Democrats worried about Harris’ lackluster poll numbers as they considered a leader of the party after Biden. “Harris has become a source of tension among Democrats, as growing worries over Harris’ political stature collide with concerns that any move to sideline her would alienate the voters needed to win elections and undercut the party’s promise of equity,” The Times wrote in 2021.
• After the Supreme Court struck down Roe vs. Wade, Harris emerged as a leading voice in protecting reproductive rights.

• Barabak in early 2024 rated her this way : “Harris finally seems to have found her footing in a role to which she is accustomed and adept: prosecuting attorney.”
• Harris has endured unprecedented levels of hate on social media. “Research shows that Harris may be the most targeted American politician on the internet, one who checks every box for the haters of the fever swamps: She’s a woman, she’s a person of color and she holds power,” The Times found.
• Before Biden’s disastrous debate performance, Harris was still struggling to present herself as a successor. “More than three years into the oldest president in history’s first term, his understudy has failed to win over a majority of voters or convince them that she is ready to step in if Biden falters, according to polls ,” The Times reported in April.
• Harris’ star rose as Democrats began to call on Biden to step aside and end his reelection campaign. She had remained publicly supportive of Biden, even as calls for her to replace him at the head of the ticket grew louder.

The abortion debate is giving Kamala Harris a moment. But voters still aren’t sold

April 16, 2024

Letters to the Editor: Should Kamala Harris step aside as Joe Biden’s running mate?

April 23, 2024

Kamala Harris: Vice president on front lines of political crisis

July 7, 2024

Kamala Harris faces political pressure — and opportunity — as Biden struggles

July 3, 2024

Correction: A earlier version of this story incorrectly stated Harris was the first person of color elected to the U.S. Senate from California. She was the first woman of color elected to the Senate.

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Though most Americans get local political news, few are satisfied with its quality

The pew research center study also found a gap between interest in news about local elections and the ability to access such coverage..

Though the majority of Americans are interested in and get local political news, only a quarter of those individuals are satisfied with the quality of the news they are getting, according to a Pew Research Center study released Wednesday.

The study, which examines how Americans get news about local government and politics, is based on a January survey of 5,146 adults and reveals two gaps, lead researcher Luxuan Wang said. The first is between the rate of Americans’ consumption of local political news and their satisfaction level, and the second is between people’s interest in news about local elections and their ability to access such coverage.

Sixty-eight percent of participants said they “often” or “sometimes” get local news about government and politics, beating topics like the economy, schools and sports. (Only local weather news and local crime news saw higher rates of consumption.) However, government and politics ranked last in terms of satisfaction; just 25% said they were “extremely” or “very” satisfied with the local political news they received.

Friends, family and neighbors serve as the most common source of local political news, researchers found. Seventy percent of respondents said they “often” or “sometimes” get local political news from the people close to them, while 66% cited local news outlets as a source they turn to. 

Social media came in third, with 54% of participants saying that they “often” or “sometimes” get their local political news there. That percentage is much higher among younger adults. More than 70% of people under the age of 30 said they turn to social media for their local political news, compared to 36% of people 65 and older.

One possible reason for the low satisfaction rate is that Americans have a hard time finding information about local elections. Researchers found that while 70% of participants said they are at least “somewhat” interested in local elections, only 45% said it was “very” or “somewhat” easy to find the information they need to make voting decisions. 

The difficulty in accessing information about local elections comes at a time when many local news outlets are shrinking or closing down completely. More than 130 local newspapers closed or merged in 2023, according to a study by the Medill School of Journalism at Northwestern University . Roughly 56% of counties in the U.S. have one or fewer local news outlets.

Interest in and access to news about presidential elections is higher, researchers found. More than 80% of participants said they are at least “somewhat” interested in presidential elections, and 59% said it is “very” or “somewhat” easy to find information for those elections.

Though the study did find low levels of satisfaction with local political news, Wang said newsrooms should take note of the high interest among Americans in local elections: “This is a really important topic for them.” That interest spans political beliefs, she added.

“When it comes to local political news, there’s a relatively low level of polarization,” Wang said. “In our study, there’s virtually no difference between Republicans and Democrats … concerning how often they get their local political news and how satisfied they are with the quality of the news they get.

“So that means local political news might actually be a common ground for partisans.”

The report is the second installment in a three-part study Pew Research Center is conducting into Americans’ local news habits. The first part found that the majority of Americans believe local news outlets are doing well financially . The third part, which will be released in the coming months, will focus on local crime news. 

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• The Buzz on Florida Politics

Abortion amendment group asks Florida Supreme Court to nix rewritten statement

• News Service of Florida

TALLAHASSEE — A political committee leading efforts to pass a constitutional amendment on abortion rights has asked the Florida Supreme Court to invalidate a revised “financial impact statement” that would appear on the November ballot with the initiative.

The Floridians Protecting Freedom committee on Wednesday filed a petition contending that House Speaker Paul Renner, R-Palm Coast, and Senate President Kathleen Passidomo, R-Naples, did not have the authority to direct a panel to revise the statement after a circuit judge rejected an earlier version.

Financial impact statements provide estimated effects of proposed constitutional amendments on government revenues and the state budget. A panel known as the Financial Impact Estimating Conference issued a revised statement July 15, but Floridians Protecting Freedom contends the statement is politicized and inaccurate.

The petition filed at the Supreme Court said the statement could have only been revised after a court order, not because of direction from state leaders.

“The state’s lack of authority to unilaterally revise a financial impact statement does make good sense,” Floridians Protecting Freedom attorneys wrote. “Consider the chaos caused by the alternative: The state could change financial impact statements on a whim, at any time, for any reason — providing sponsors, litigants, and the public little or no time to digest the statements or to challenge them before they are irrevocably placed on the ballot.”

The Financial Impact Estimating Conference released an initial statement for the proposed amendment in November 2023. But on April 1, the Supreme Court issued a ruling that allowed a six-week abortion limit to take effect.

Floridians Protecting Freedom filed a lawsuit on April 5 arguing that the November financial impact statement needed to be revised because it was outdated after the Supreme Court ruling. Leon County Circuit Judge John Cooper agreed and ordered the Financial Impact Estimating Conference to draft a new version.

State lawyers appealed, arguing that Cooper did not have legal authority to issue such an order. Amid the appeal, Renner and Passidomo directed the Financial Impact Estimating Conference to revamp the statement.

The revised statement led the 1st District Court of Appeal on Monday to dismiss the pending legal case , saying it was moot.

“The result is that, absent this (Supreme) Court’s intervention, the state intends to place a Financial Impact Statement on the ballot that is plainly misleading in contravention (of a Supreme Court precedent and a section of state law) and the circuit court order,” Wednesday’s petition said. “But here’s the thing. This (Supreme) Court need not — and should not — sanction this unlawful outcome, for one very simple reason: The state never had the power to reconvene the conference and revise the statement outside the parameters established by the circuit court.”

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The proposed constitutional amendment will appear on the ballot as Amendment 4. It says, in part, that no “law shall prohibit, penalize, delay, or restrict abortion before viability or when necessary to protect the patient’s health, as determined by the patient’s healthcare provider.”

Gov. Ron DeSantis and other state Republican leaders are fighting the proposed amendment. Representatives of DeSantis and the House spearheaded revisions in the financial impact statement.

In part, the revised statement says there is “uncertainty about whether the amendment will require the state to subsidize abortions with public funds. Litigation to resolve those and other uncertainties will result in additional costs to the state government and state courts that will negatively impact the state budget. An increase in abortions may negatively affect the growth of state and local revenues over time. Because the fiscal impact of increased abortions on state and local revenues and costs cannot be estimated with precision, the total impact of the proposed amendment is indeterminate.”

By Jim Saunders, News Service of Florida

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