When Heather-Elizabeth Brown spiked a fever in April in Detroit, the only reason she was able to get a coronavirus test was because she was volunteering as a police chaplain and was therefore considered an essential worker. Her results came back negative, and she was relieved. But then, she says, “I just got sicker and sicker.” 

After being turned away from overcrowded ERs twice, Brown was eventually admitted on her third try. She finally tested positive, and by that point, she was severely ill. She was put on a ventilator and spent the next 31 days in a medically induced coma. 

Before Covid-19, Brown was a healthy, active Black woman in her 30s. “But when I came off the ventilator, they had to coach me how to breathe.” The smallest pleasures — like eating a sliver of ice after her feeding tube was removed — became something to treasure.

Six months later, Brown is still very ill. She has been hospitalized for blood clots and has lingering heart problems, nerve pain, and extreme fatigue. “Even making breakfast is now out of the question,” she says. Most troublingly, she’s still experiencing severe brain fog, which makes it hard for her to return to work. 

Brown is just one of many previously healthy people whose life has been derailed after a Covid-19 infection. While early research on Covid-19 focused on its respiratory symptoms, we now know its impacts — both direct and indirect — can be much more extensive and relentless.  

On December 3, the National Institutes of Health held a two-day seminar on what has come to be called long Covid, or long-haul Covid — cases of lingering symptoms that can last for weeks or months after an initial infection. The Centers for Disease Control and Prevention (CDC) recently created a list of some of the persistent symptoms patients are experiencing, which include chest pain, brain fog, fatigue, and hair loss — with patients reporting many others as well.

Because these patients don’t all have the same symptoms, they will need different kinds of post-Covid care. And the NIH made clear that there are still many more questions than answers — including whose symptoms might linger for months, and how to treat them.  

Almost a year into the pandemic, there have not yet been thorough, large-scale studies to determine the true prevalence of long Covid. But preliminary research suggests that somewhere between 10 percent and 88 percent of Covid-19 patients will experience at least one symptom for many weeks or months. Some of these can be life-altering; one study found that 50 percent of non-ICU patients reported a significant change to their cognitive functioning. 

Doctors at the seminar said they were surprised by the scope of long Covid and its potential socioeconomic impacts. “This is a phenomenon that is really quite real and quite extensive,” said Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, who spoke at the event.

Even if the prevalence ends up being on the lower end of the 10 to 88 percent range, the sheer volume of people getting sick means there are already millions of Americans who have, and will soon have, long Covid. Despite the staggering numbers, “we’re a hidden group of people,” Brown says. This can make getting treatment from skeptical physicians challenging. Long-Covid patient Anthony Campbell, for example, had a doctor refuse to sign a work disability form unless he was treated for anxiety rather than for his persistent symptoms. 

Interviews with dozens of patients like Brown and Campbell provide a closer look at long Covid’s devastating impact — and the clues the latest research offers into what might be causing all these symptoms, including erectile dysfunction, hormonal imbalances, hallucinations, and dementia-like effects that can severely impact daily life. 

Menstrual changes and erectile dysfunction

One of the most surprising new findings about long Covid’s effects is that both women and men have reported sexual and reproductive system symptoms following a Covid-19 infection. 

The Patient-Led Research Group, a team of researchers who are also Covid-19 patients, conducted a survey of 640 long-Covid patients and recorded more than 200 total symptoms, including testicular pain, urinary problems, and menstrual changes. 

“A lot of people with long Covid notice that their symptoms get worse just before their period happens,” when estrogen levels are lowest, says Louise Newson, a general practitioner and menopause specialist. She says an additional sign hormones may be involved are long-Covid symptoms like “brain fog, fatigue, dizziness, joint pain — these are also symptoms of menopause.”

Newson has 842 patient responses so far to a pilot survey, and she says the results “confirm my thoughts that long Covid is likely to be related to low hormone levels (estrogen and testosterone), which so far have been neglected with research.” Estrogen plays a key role in women’s health, and having abnormally low levels can lead to infertility, osteoporosis, lack of sex drive, and depression. 

Newson says that anecdotally, patients with long Covid from her menopause clinic have improved with the right dose and type of hormone replacement therapy. “They all had low oestradiol and low testosterone results before treatment,” she says. 

Long Covid can also significantly impact male reproductive systems and testosterone levels. “Absolutely, reproductive systems have been overlooked during the pandemic,” says Geoff Hackett, a professor of sexual medicine at Aston University in Birmingham, UK. He explains that during acute illness, the testes can be attacked by the virus directly.

“The testes are one of the highest sites of ACE2 expression,” writes the British Society of Sexual Medicine (BSSM) in its position paper on Covid-19. (This ACE2 enzyme is the primary way SARS-CoV-2 enters cells.) The BSSM adds that SARS-CoV-2 also damages cells on the inner surface of blood vessels called endothelial cells, a condition which is “frequently present in men with erectile dysfunction and testosterone deficiency.”

Several recent studies have pointed to testosterone, which in men is produced in the testes, as playing an important role in coronavirus patients: A study in Germany found that the majority of men admitted to the hospital with Covid-19 had low testosterone levels and high inflammatory markers. (This study was unable to determine if these low testosterone levels predated their coronavirus infection.)

A similar study in Italy found low testosterone levels predicted worse outcomes in hospitalized patients. A third study, in Wuhan, China, also found low testosterone levels in coronavirus patients, which they said required “more attention to gonadal function evaluation among patients recovered from SARS-CoV-2 infection, especially the reproductive-aged men.”

Hypogonadism, when sex organs don’t produce sufficient hormones, affects both the production of testosterone and sperm. Another recent paper, published in The Lancet, found the production of sperm was impaired in Covid-19 patients, which they said might be explained by an immune response in the testes. In some patients, they also found auto-immune orchitis, or inflammation of the testis with specific anti-sperm antibodies. “There does seem to be some evidence for relative infertility afterward,” Hackett says, though he cautions it’s too early to say if it would be permanent. 

In general, “attacking the cells of the testes will have an adverse effect on erections,” Hackett says. Even beyond a direct effect, endothelial disorder and inflammation may affect the arteries in the penis, making erections more difficult. “Erectile dysfunction is going to be highly prevalent, particularly if you look at the groups at high risk of Covid-19,” Hackett says. “Seventy-five percent of diabetics have erectile dysfunction anyway.” Based on anecdotal evidence, the next Patient-Led Research Group survey will include questions on shrinkage, erectile dysfunction, and testicular pain. 

Erectile function is a sign of overall health, and urologist Ryan Berglund of the Cleveland Clinic recently made a statement that for young and healthy people who develop this problem after having Covid-19, “this can be a sign of something more serious going on.” 

The BSSM is concerned that these reproductive effects may have lasting implications, warning that low testosterone levels in men “are associated with increased mortality,” and that those “who may have survived the current pandemic … may be at considerable risk from second and third wave infection, or future viral pandemics.”

Beyond Covid-19, research suggested a connection between viral infections of the central nervous system and pituitary dysfunction. A significant number of viruses have previously been associated with the onset of Type 1 diabetes, and it appears there may have been an increase in diabetes diagnoses during the pandemic.

Recognizing these impacts may help doctors find effective treatments; Hackett says a common erectile dysfunction treatment, Tadalafil, improves all markers of endothelial disease. “If it didn’t give men an erection, it would be treated as a serious cardiovascular drug,” he says. He notes that mountain climbers often take Tadalafil before big climbs to avoid altitude sickness, as it lowers pulmonary artery pressure and improves the endothelium of arteries — effects that might significantly help Covid-19 patients.

But Hackett says even as the UK National Health System rolls out long-Covid clinics, he’s been disappointed to see these symptoms overlooked. “Their strategies include things like eating healthy, hydrating, and mindfulness,” he says. “How is this going to go down with seriously ill people? All they’re offering is platitudes.” 

Pulmonary problems

Long-Covid symptoms can be very diverse and are often not limited to one part of the body, making them hard to understand. One of the reasons long-Covid patients are struggling to do high-quality research through their illnesses, says Hannah Davis, a long-Covid patient and a member of the Patient-Led Research Group who helped design the survey, “is that we need answers.”

She’s tired of being told that no one knows how to help treat her symptoms, or how many others might be experiencing something similar. “We’re going to get answers faster than anyone else because we’re living this experience,” Davis says. One recent study of 201 long-Covid patients in the UK found that even in a young, low-risk population, 66 percent had impairments to one or more organs four months after their initial symptoms. 

Being sick enough to be ventilated, like Brown was, often comes with its own complications; one study found that 81 percent of ventilated patients develop delirium, and one in five patients with acute respiratory distress syndrome — a common lung condition in ICU patients — experience long-term cognitive impairment. But even coronavirus patients with milder symptoms or no initial symptoms at all can develop long Covid.

Long-term lung problems are perhaps the most straightforward long-Covid symptom, as the virus can directly inflame the lung tissue, filling air sacs with fluid and making them less elastic and harder to expand as you breathe. Even at the beginning of the pandemic, it was known that previous coronavirus epidemics had caused lung scarring in some patients. One 15-year study of 71 SARS patients from a 2003 outbreak found a third had reduced lung capacity; a third of MERS survivors in a 2017 study also had long-term lung damage. 

New research suggests that around half of asymptomatic Covid-19 infections can also cause damage to the lungs.

In early November, a study published in The Lancet on 41 autopsies of Covid-19 patients offered a possible reason: It found that the virus caused major structural changes in the lungs, including extensive blood clotting, scarring of respiratory tissue, and the fusion of many smaller cells into larger cells. (Based on the fact that these were autopsies, these were all severe cases, limiting the implications that can be drawn.) 

The authors suggest that, unlike other types of pneumonia, these structural changes may stem “from the persistence of infected and dysfunctional cells in the lungs” — which may help explain why some of these symptoms linger. Though we still don’t know the exact mechanics, continuing lung symptoms are perhaps the most common of them. 

It’s still unclear how long these symptoms might last; some long-Covid patients have reported improvements in their breathing, although much slower than they would have liked. One study of mildly ill patients in China found that 70 percent had abnormal lung scans three months after their initial illness.

Blood clotting and other cardiovascular issues

Early in the pandemic, doctors noticed that many Covid-19 patients were having serious blood clotting problems, with reports of clogging dialysis machines and clots in the arms and legs called deep vein thromboses. But some patients, like Brown — who went back to the hospital with blood clots three months after her initial symptoms — are also experiencing clots weeks or months later.

Large blood clots can cause tissue damage, requiring amputations. Smaller clots can restrict blood flow in the lungs, impairing normal oxygen exchange. If clots travel to the brain or heart, they can also cause strokes or heart attacks, as 23-year-old Riley Behrens recently suffered after a coronavirus infection. “Before this, I was a healthy young athlete with no major medical conditions,” she tweeted after a Covid-related stroke. “Now, I’m being told I will likely never return to contact sports because of lasting lung and brain damage. The risk for a second stroke will always be there.”

It’s hard to know how common clotting problems are in Covid-19 patients, but reports of conditions linked to clotting have certainly increased: A study published in Annals of Vascular Surgery recently found a twofold increase during the pandemic in major amputations, which are sometimes required after a clot is found. And multiple researchers have reported a spike in the number of stroke patients, including young people like Behrens who would not normally be at high risk for strokes, as well as in patients who didn’t know they’d had the coronavirus but later tested positive for antibodies.

A study published in Science in mid-November may have identified one of the reasons for this abnormal clotting: In half of 172 hospitalized coronavirus patients, the scientists found autoantibodies — proteins that are supposed to defend against invaders that instead start to attack the body’s own cells. When these autoantibodies were injected into lab mice, the animals developed blood clots. The researchers suggest that these proteins could be sparking a dangerous loop between clotting and hyperinflammation. A December preprint also found a significant percentage of Covid-19 patients developed autoantibodies, and the more severe their symptoms, the more autoantibodies they had.

But Covid-19’s cardiovascular impacts don’t end with coagulation. Half of 1,216 Covid-19 patients in one study also had heart abnormalities, and one in seven had severe cardiac issues.

“People can present without any lung symptoms, and have just heart or brain involvement,” says Eric Topol, a professor of molecular medicine and director of the Scripps Research Translational Institute. These can include cardiomyopathy, a disease of the heart muscle that makes it harder for your heart to pump; myocarditis, or inflammation of the heart muscle; and pericarditis, inflammation of the pericardium, the two thin layers of tissue that surround the heart and help it function. One study on 54 college athletes who’d had mild Covid-19 cases found that a third had pericarditis, even though about the same number had been asymptomatic. 

Many long-Covid patients are also experiencing persistent heart concerns months after their initial illness. Kate Meredith of Beverly, Massachusetts, for example, first got sick in March. Now, she has tachycardia, or an abnormally elevated heart rate. “If I get up to do the dishes, it jumps to 140 [beats per minute],” she says.

Leticia Soares and Israel Slick, of Ontario, both also got Covid-19 in April. They each independently reported heart palpitations and tachycardia to the same doctor, who speculated Slick’s condition might be related to his Covid-19 infection, while Soares, who is Latina, was told to seek counseling. (Many Black and brown long-Covid patients say they’ve experienced gaslighting and medical racism when they try to seek treatment.) 

Cardiovascular symptoms may arise from the coronavirus directly impacting the endothelium. These cells control vascular functions, including enzymes that direct blood clotting. The endothelium is also important for proper immune function, and its imbalance could help explain the cytokine storms seen in many patients with severe Covid-19 cases. “There’s no shortage of ways by which this virus can hurt the heart,” Topol concludes.

Immune system

Damaged endothelial cells can also stimulate mast cells, a type of blood cell that’s part of the immune system. Their job is to defend against foreign bodies by releasing chemicals like histamines. Activated mast cells were recently found in autopsies of Covid-19 patients and are linked to clots and pulmonary edemas.

Some long-Covid patients are reporting symptoms and inflammation similar to mast cell activation syndrome (MCAS), a chronic, multisystem condition that causes allergic responses, GI problems, and neurological issues.

Frances Simpson, a psychology lecturer at Coventry University in the UK, says she and her 5- and 9-year old were infected with Covid-19 in March and have had long-Covid symptoms since, including new allergic reactions. “When you read about possible mast cell activation syndrome,” she says, “we can tick all of the symptoms off between us” — things like headaches, rashes, and extreme fatigue. Moreover, some of the drugs that have been shown to help with severe Covid-19 cases, like famotidine and aspirin, inhibit mast cell activation. 

Immunology is very complicated, but it also appears that T cells, an important component of the immune system, may also play a role in long Covid, as they do in other inflammatory and autoimmune conditions. 

The CDC is now calling a particular set of inflammatory symptoms in multiple organs after an initial infection multisystem inflammatory syndrome in adults, or MIS-A — after a similar post-viral condition that was first reported in children, called MIS-C. Both children’s and adults’ symptoms in these cases overlap with MCAS, with problems like chest tightness, abdominal pain, rash, and inflammation, strengthening the argument that mast cells may be involved.

Nervous system

New research is also homing in on the many, sometimes severe, neurological symptoms that long-Covid patients have reported. One peer-reviewed paper found that a surprising 40 percent of patients with Covid-19 showed some kind of neurologic manifestation, and more than 30 percent had impaired cognition. These symptoms — including brain fog, extreme fatigue, difficulty with short-term memory, intense headaches, and tingling or numbness — are common in long-Covid patients. 

Some long-Covid patients develop dysautonomia, a disorder of the autonomic nervous system that can be triggered by viral infections. The autonomic nervous system controls involuntary functions in our bodies such as heart rate and digestion. When it is damaged by an infection, these functions can go out of whack. 

Davis, for example, has been diagnosed with a form of dysautonomia called postural orthostatic tachycardia syndrome (POTS), where blood vessels don’t respond to chemical signals efficiently. When she stands, blood pools in her lower extremities, making her feel faint and exacerbating her brain fog. The nervous system continues to release hormones to tighten her non-responding blood vessels, increasing her heart rate and making her shake.

There’s also increasing evidence that SARS-CoV-2 can actually cross the blood-brain barrier, a layer of specialized cells that protect the brain, and harm the nervous system directly. In April, researchers found that a 40-year-old woman in Los Angeles with headaches, seizures, and hallucinations had RNA from the coronavirus in her cerebrospinal fluid.

One study recently found an explanation for how that may have occurred: The virus can directly enter and damage cells in the brain’s choroid plexus, which has cells with ACE2 receptors. “This can lead to leakage across this important barrier, that normally prevents entry of pathogens into the cerebrospinal fluid and the brain,” says study co-author Madeline Lancaster, a biologist and the group leader at the MRC Laboratory of Molecular Biology in Cambridge, UK.

The brain is normally protected from your blood, so it’s a big problem to have that barrier penetrated. During viral infections, many immune cells are activated and circulating through the body. Lancaster explains that even if the virus itself doesn’t get past the barrier, having “those inflammatory cytokines leak into the brain, where they really do not belong, can have serious repercussions.” One example is encephalitis, or inflammation of the brain itself, as found in this study of 12 Covid-19 patients in the UK. 

Lancaster says viruses may penetrate the blood-brain barrier more often than previously thought. “The Covid crisis has shined a light on overlooked post-viral chronic fatigue syndrome (CFS),” she says. “There’s a lot of indication that inflammation of the brain can lead to those symptoms. There’s a huge overlap between those conditions and long Covid.” 

But though post-viral symptoms may linger for months or even years, it can be hard for doctors to find clues in neurological tests. While encephalitis can be seen on MRIs, damage to the cerebrospinal fluid might not be visible. (Doctors can, however, look for elevated biomarkers like cytokines.) “Unfortunately, that’s one of the reasons a lot of patients with CFS have been told it’s all in their heads. We’ve let those patients down,” says Lancaster.

Neuro-inflammation can cause emotional and behavioral changes. Sammie, who asked that her last name not be used to protect her privacy, says she and her daughter were both infected in the UK with Covid-19 in March. Since then, her 15-year-old daughter has had headaches, dysautonomia, fatigue, and extreme anxiety and emotional outbursts. “She’s not a crier. She’s normally very stoic,” Sammie says, but over the last few months, “she’s had irrational outbursts, just sobbing her heart out.” 

One study of 62,354 patients recently published in The Lancet Psychiatry journal found that one in five were diagnosed with a mental health disorder within three months of testing positive for the coronavirus. “But what’s the chicken and what’s the egg?” Lancaster asks. “It could be that there are people with leakier brains to start with, who when they get Covid-19 are more likely to have viral entry into their brain.”  

Neuro-inflammation might also help explain some of the weirder long-Covid symptoms reported by parents of children who have had Covid-19, like something called Alice in Wonderland syndrome, an alteration of visual perception where objects or body part sizes are perceived incorrectly. Simpson says her son’s vision regularly goes blurry, and he describes people’s heads “going small.”

Gretchen Drown of Portland, Maine, also says that her 15-year old son, who got Covid-19 in March, describes “things looking weird,” and that during these episodes, his pupils get strangely dilated. Drown’s son also now has headaches and extreme fatigue, which worsen after he overexerts himself, making it hard to keep up with school. 

Damaging the blood-brain barrier also hurts its ability to make cerebrospinal fluid, which is important for providing nutrients to the brain and removing its normal waste. Lancaster calls the cerebrospinal fluid the plumbing system of the brain. “Imagine your house with all your toilets clogged — a similar thing can happen in the brain,” she says.

Much of this fluid cycling normally occurs during sleep, so Lancaster suggests that Alice in Wonderland syndrome — and possibly other common neurological symptoms in long Covid, like extreme fatigue and insomnia — might be related to the virus compromising the body’s ability to generate and manage this fluid. 

Children and long Covid

As the pandemic began, it appeared most children had mild cases of Covid-19. But while clinicians have not been tracking long Covid in children, it’s clear from the many parents Vox interviewed that children of any age can and do experience persistent symptoms that can completely alter their ability to function. 

That no one seems to be paying attention to pediatric long-Covid cases is a source of extreme frustration. Multiple parents reported that during their efforts to get their children care, medical providers accused them of Munchausen syndrome, a psychological disorder where someone pretends to be ill.

Sammie says when a nurse suggested it to her, “I literally think if I hadn’t had a mask on, my jaw would have fallen off. I felt so broken — it makes me feel emotional talking about it now.” Since then, she’s complained to the clinic and actually gotten a letter of apology. But her experience demonstrates the hurdles parents face in getting their children the care they need. “I think there are a lot more children who are ill, and who no one is connecting the dots for,” Sammie says. 

While it’s hard to quantify something no one is tracking, the American Academy of Pediatrics suggests about 11 percent of US Covid-19 cases are children, with over 1,460,905 children contracting the virus as of December 3. It’s easier to count more acute Covid-19 consequences, like MIS-C: In one study of kids under 18 with MIS-C, 14.8 percent exhibited new neurological symptoms like headaches, muscle weakness, and reduced reflexes. The youngest child with persistent symptoms Vox found was 18 months; the oldest was 15.  

While some of the symptoms parents have reported in children are similar to adult long-Covid cases — headaches, extreme fatigue, difficulty concentrating or forming new memories, anxiety, depression, tachycardia, dysautonomia, lingering or recurrent fevers — others differ. Some parents in the long-Covid kids online group Sammie formed, for example, have been reporting frequent nosebleeds. 

Some of the parents, like Simpson, are themselves suffering from long Covid. “In many families who have kids with long Covid, there’s a mother or father who has it as well. People should be tripping over themselves to research if this is genetic,” she says. 

But in the meantime, for parents like Sammie, Simpson, Meredith, and Drown, there are few resources to help their children recover. Though it hasn’t been easy, Sammie hasn’t given up trying to get her daughter into more specialized care. “If I don’t advocate for my child, who the hell is going to do it?” she asks.

Parents worry about how their children’s lives might be impacted by the long-term effects of this disease. For adult patients, too, the repercussions are potentially huge. 

One doctor, whose family asked that her name be withheld for privacy reasons, first got sick this spring. She eventually despaired of finding treatment for her long-Covid symptoms. She recently drove to New York — because she wanted to be near the best researchers she knew of — before ending her life. She donated her body to science.  

For those who survive, like Brown, the questions are pervasive. “How will this affect me when I want to have a baby?” Brown asks. “What is next? We have no idea. No one can tell me anything specific.” She’s frustrated that friends her age still assume that if they get infected, they’ll recover. 

“You might be okay, but you might not,” Brown says. She says she’s angry about how the pandemic has been measured in deaths rather than in lives disrupted. “The disparities are shocking. And more will be lost if we don’t make adjustments.”

Lois Parshley is a freelance investigative journalist. Follow her Covid-19 reporting on Twitter @loisparshley.

Deborah Birx, the coordinator of the White House coronavirus task force, toured North Dakota this fall, as the state was overwhelmed by one of the worst Covid-19 outbreaks in the country. While she commended the state’s testing efforts, she was distraught by the noticeable lack of face masks in public spaces. “This is the least use of masks that we have seen in retail establishments of any place we have been,” she said at an October 26 press conference. 

North Dakota, which at the time didn’t require masks, had the lowest mask-wearing rate in the country in October, according to survey data.

North Dakota is not the only state that lagged in a mask policy in the throes of a major outbreak, however: Eight of the top 10 states that saw the highest new cases per capita in October did not have a widespread mask mandate, as the chart below shows. (Several of these Great Plains and Midwestern states were spared significant outbreaks of the virus until the fall.)

But the dramatic surge of Covid-19 across the country this fall and winter has forced some states to change course. On November 8, Utah implemented a mask mandate, as new daily Covid-19 cases continue to rise in the state and across the country. Several other states have implemented or tightened mandates since then, including Iowa and North Dakota. Thirty-seven states now have mandates, according to the AARP.

And on December 4, the CDC issued a new recommendation that people wear masks indoors at all times, unless they are at home.

Over the course of the pandemic, America has been engaged in a massive and uncontrolled mask experiment: Some jurisdictions implemented and enforced mask mandates; others rejected them as public health guidance became politicized. President Donald Trump has repeatedly questioned and even scorned the use of masks, and several Republican governors have followed his lead. President-elect Joe Biden, meanwhile, has called for a national mask mandate and for Americans to wear masks for the “first 100 days” he is in office, as vaccines roll out.

But the different state-level approaches mean researchers can now parse the results of a trial they never would have received approval to conduct. New research from Kansas and Tennessee suggests that not only do mask mandates prevent Covid-19 spread, they may also blunt the severity of illness and reduce the number of serious cases that require hospitalization. Other findings support the argument more and more public health experts are making: that masks remain among our cheapest most effective tools to control the pandemic — if worn consistently. 

“If you’re not in the ICU, the only tools at our disposal that we know work are the tried-and-true public health measures, like social distancing, hand-washing, and masks,” says Vin Gupta, a critical care pulmonologist and affiliate assistant professor for the Institute for Health Metrics and Evaluation at the University of Washington. “We’re bearing the brunt of those things being implemented poorly.”

“You’re less likely to get Covid-19 if you’re wearing a mask,” says Donna Ginther, an economist and director of the Institute for Policy and Social Research at the University of Kansas. And “even if you do get sick while wearing a mask, you’re less likely to get deathly ill.” 

Let’s walk through some of the latest research on mask mandates and what it means as we head into one of the most perilous seasons in the pandemic so far.

New evidence from Kansas and Tennessee that mask mandates control the spread of Covid-19 

One intriguing piece of evidence of the effect of mask mandates on controlling the spread of the virus comes from Kansas. In July, Laura Kelly, the Democratic governor of Kansas, issued a mandate requiring everyone in public places to wear a mask where 6 feet of social distancing couldn’t be maintained. It prompted an immediate outcry from conservatives. Because of a state law passed in June that allowed counties to supersede the governor’s emergency powers, 81 counties out of 105 opted out of the mask mandate altogether, and only 21 counties decided to enforce it.

Two researchers from the University of Kansas analyzed what happened next.

Ginther, the economist working on this analysis, found that in the counties that enforced mask-wearing, new cases stayed roughly steady. But in the counties without mandates, even after controlling for how often people left their homes, they doubled. “We were stunned by the strength of the effect,” she says. 

The public health officer of Johnson, the state’s largest county, was so impressed he asked Ginther to share her work with the Board of County Commissioners, even though it’s not yet peer-reviewed or even written up into a paper. She is currently working on publishing the results.

Ginther says it wasn’t until 12 weeks after the mandates took effect that the growth in cases began to slow. But she thinks her results are likely conservative. “A 50 percent reduction in cases is likely to be a lower-bound on the true effect of wearing a mask,” she says. “If you had 100 percent compliance, I would expect to see an even larger effect.” 

Other researchers have made related findings. A nonprofit group called Prevent Epidemics recently published a report showing that, following mask mandates, coronavirus cases declined in Alabama, Oklahoma, South Carolina, and Texas. The CDC found that in Arizona, after a mask mandate was put in place, Covid-19 cases dropped 75 percent. Conversely, cases spiked 151 percent when stay-at-home orders were lifted, demonstrating that behavior has a significant impact on viral transmission. 

In addition to slowing the spread of the virus, new evidence from Tennessee shows that mask mandates could reduce the severity of the virus. A paper by researchers at Vanderbilt found that at Tennessee hospitals where at least 75 percent of Covid-19 patients came from counties with mask requirements, coronavirus hospitalization rates are the same as they were in July. In hospitals where fewer than 25 percent of patients come from places with a mask mandate, hospitalizations are 200 percent higher. What’s more, the researchers wrote, hospitals in areas with mask requirements and other mitigation strategies “are in a much better position to serve the entire spectrum of community health needs, not just Covid-19 patients.”

Mask mandates lead to more people wearing masks

Even if they aren’t always followed, mask mandates appear to be an effective tool in encouraging behavior change. The Institute for Health Metrics and Evaluation (IHME) at the University of Washington found in August that mask use increased 8 percentage points after mask mandates, and increased 15 points if those mandates were enforced.

Only around 65 percent of Americans currently regularly wear masks, according to IHME. But in Singapore, for instance, around 95 percent of people wear masks, and they have one of the world’s lowest coronavirus death rates. “We know that countries that wear masks are doing much better,” says Ali Mokdad, the chief strategy officer of public health at the University of Washington.

Thirty-three states and Washington, DC, implemented statewide mask mandates between April and August. During the same period, an increasing number of Americans began to wear masks regularly, according to a weekly survey started in mid-April by the data intelligence company Premise. 

There is one caveat of all the analyses mentioned above: They simply observe behavior, which means that they can demonstrate associations — like case counts falling after mask mandates are put in place — but not causation. The gold standard to prove that would be a randomized controlled trial. But that’s a hard study to design in a pandemic because of ethical concerns. 

Even without randomized trials, Rebekah Gee, a public health policy expert and secretary of the Louisiana Department of Health, says the body of evidence “confirms what public health experts have known since early on in this pandemic, which is that masks work.”

Masks could save 130,000 lives by February, but more Americans would have to wear them consistently

In fact, a study published October 23 in Nature Medicine by IHME’s forecasting team modeled current public health interventions — projecting case numbers based on current behavior — and found that universal mask use could save as many as 130,000 lives by the end of February 2021. 

Mokdad says that’s why it’s essential to have clear, consistent recommendations to wear masks. He adds, “We never debate seatbelts. Is it okay if only 80 percent of people wear them? We say everybody should.” But while he would prefer that 100 percent of people wear masks, Mokdad says at this point, any incremental increase in mask use “for me is a celebration.”

Unfortunately, in many parts of the US, mask use is actually decreasing. In Florida, for example, which grappled with a serious surge in cases this summer, Mokdad says 70 percent of people were wearing masks in August. Now, only 65 percent are. “Wearing masks has been a response to fear rather than a good, persistent behavior,” Mokdad says. 

Vox analyzed the relationship between the frequency of wearing masks from the Premise survey data and the Covid-19 cases in states from April to October. As the charts below show, in states with mandates where cases surged in the spring, more people now wear masks. These states — where more people consistently wear masks — are now less likely to see another huge surge in cases. 

Even though mask use has risen in many states, the nation as a whole is on a troubling trajectory, with new daily cases, hospitalizations, and deaths all on the rise. Mokdad says he’s very concerned about the holidays. “As we go be with our loved ones — our grandparents, our kids — do you want to go sit at a table and risk the people you care about most, or do you want to wear a mask?” IHME models predict that if some US states increased their mask use from now on, they could reduce the number of future Covid-19 deaths by about 50 percent.

The stakes for getting this right are high — not just for the holidays, but for the rest of the pandemic, however long that might be. 

Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, recently echoed Biden’s call for a national mask mandate. “If you don’t want to shut down, at least do the fundamental, basic things,” Fauci told the editor-in-chief of JAMA, “the flagship of which is wearing a mask.”

Rather than thinking about a mask mandate as something that takes away a freedom, as anti-mask protestors have claimed, Leana Wen, a physician and the former Health Commissioner for the City of Baltimore, says, “Mask-wearing allows you to do things.” If everyone wears a mask, it will keep transmission low, allowing businesses and schools to stay open. 

“If you want a more normal life, we need to adjust our behavior, as opposed to locking ourselves away,” Ginther says. “Masks rise to the top as an approach we can take as a society to have a more open economy but not get everyone sick.”

Lois Parshley is a freelance investigative journalist. Follow her Covid-19 reporting on Twitter @loisparshley.

Editor’s note, November 7: Due to a data error, a previous version of the chart of increases in Covid-19 cases in October did not include Hawaii and miscategorized Louisiana as not having a mandate. In fact, Louisiana implemented a mandate in August. The chart has been updated to reflect these changes.

On March 15, Melanie Montano woke up with a fever and chills. Her Covid-19 symptoms progressed quickly; she lost her sense of smell and taste and had trouble breathing. 

Seven months later, she’s still struggling with fevers, brain fog, fatigue, and pain in her arms and legs. She’ll feel better some days, only to feel worse the next, in what she calls the “coronacoaster.” 

With 8 million cases of Covid-19 now confirmed in the US, stories like Montano’s are becoming increasingly common. But you might not know it from listening to President Trump. In his first extended statement in October since his own diagnosis, he falsely implied that everyone infected with the coronavirus can expect a rapid and full recovery. “Now what happens is you get better,” he said. “That’s what happens, you get better.” 

For many diagnosed with Covid-19, nothing could be further from the truth. Preliminary research suggests at least 10 percent of people — and possibly many more — may continue to have symptoms for at least two months after infection.

“When Trump says ‘don’t be afraid of it’ — I’ve been so angry in the last week, I’m just trying to calm down,” says Kate Meredith of Beverly, Massachusetts, who has been experiencing Covid-19 symptoms since mid-March.

To this day, Meredith has fevers four to five days a week. “I go up one flight of stairs and can’t breathe,” she says. She also now has tachycardia, a heart condition where standing up too quickly makes her heart rate jump to 140. Since March, she has been to the emergency room three times, and to the doctor 35 times. She still gets debilitating headaches almost daily, and has run out of her two and a half months of medical leave. 

Meredith and Montano are among thousands of people who have continued to experience extended symptoms or suffered relapses after an initial coronavirus infection. As new information emerges about the many, varied impacts that can linger, patients are facing doubt from doctors and structural failures that loom over an uncertain future.

What percentage of Covid-19 patients have persistent symptoms?

There have been a number of studies now trying to answer this question, but there isn’t consensus about the true prevalence of long-term Covid-19 symptoms. Much of the preliminary research has been limited to small numbers of patients, and many focus on hospitalized patients, obscuring what happens to milder cases. 

For example, one study out of Wuhan, China, of 153 non-hospitalized confirmed coronavirus patients found that 22 percent of patients had experienced symptom relapse, and 11 percent of patients had symptoms for more than eight weeks. (It also found a whopping 77 percent of patients had neurological symptoms.)

Other research focusing on outcomes for severely ill Covid-19 patients who were hospitalized reports worse odds, like one study in Italy that found 87.4 percent of people had not totally recovered after 60 days. (That said, recovery from intensive care for any illness can take weeks or months; for example, only 33 percent of sepsis patients have returned to work within three months.) Of the 143 patients in the study, 55 percent still had three or more symptoms, like fatigue, chest pain, and shortness of breath, at day 60. 

Another study followed hospitalized patients for nearly twice as long, 111 days. They also found that 55 percent of patients continued to have fatigue, 42 percent had shortness of breath, and 34 percent reported loss of memory.

Yet another study of more than 112 hospitalized and 2,001 non-hospitalized patients in the Netherlands found that only 0.7 percent of people were symptom-free 79 days after their infection. (The most common symptoms were fatigue and difficulty breathing, although the number of symptoms people experienced decreased over time.)

Studies that include non-hospitalized patients can have limitations in how they find participants, and in their sample sizes. The COVID Symptom Study, for instance, has asked people to self-report their symptoms into an app after their diagnosis. Analyzing data from 4 million people in the US, UK, and Sweden, the researchers found that approximately 10 percent of people experience prolonged illness for more than three weeks after Covid-19. But many users have reported frustration with the app not including certain symptoms, or needing to answer questions daily that didn’t feel applicable, so user retention suffered. 

The National Institutes of Health recently updated its Covid-19 guidelines to include a description of persistent symptoms. These state that neurologic and psychiatric symptoms have been reported in coronavirus patients, including high rates of anxiety and depression, particularly in younger patients. They add that patients may experience “headaches, vision changes, hearing loss, loss of taste or smell, impaired mobility, numbness in extremities, tremors, myalgia, memory loss, cognitive impairment, and mood changes for up to 3 months” after their initial illness. 

No one has yet defined how long “long Covid” might last — many of the studies simply stopped tracking people after a set time. But research on other severe coronaviruses like SARS shows that 40 percent of previously hospitalized patients had chronic fatigue symptoms 3.5 years after their diagnosis. Clinicians and patients don’t know what this might mean for Covid-19 patients with persistent symptoms. 

Leonard Jason, a professor of psychology at DePaul University and director for the Center for Community Research, is enrolling participants in two studies to try to help understand risk factors in both children and adults with long Covid. “There’s almost no questions that have been answered,” he says. “We really don’t know a lot.” 

People with cardiac or lung problems may have sustained damage to their organs, but many people are also experiencing symptoms without good explanations, he says. “Some people stay ill, even when they seem okay” from clinical tests, he said. “That’s a massive challenge.”

Mike Ryan, the executive director of WHO’s Health Emergencies Program, said at a press conference that right now, long Covid is a risk “that you cannot quantify.” But, he said, it’s still a huge reason to stop the spread of the virus. “We need to avoid all Covid-19 infections, both in terms of reducing transmission but also in reducing the long-term health impacts of this disease.”

Who is most at risk of developing long Covid?

Long-term Covid-19 is not equally distributed among the population. Just like the initial viral severity, these lingering symptoms seem to hit those with certain risk factors more frequently. 

The World Health Organization says that risk factors for persistent symptoms include high blood pressure, obesity, and mental health conditions. But many previously healthy and active people have also had long-term issues. 

In one study of 139 hospitalized patients in Wuhan, the median age of those with persistent symptoms was 55, and half previously had one or more other conditions, like hypertension, diabetes, or heart disease. But the study only looked at patients with severe initial symptoms. 

The US Centers for Disease Control and Prevention conducted a telephone survey of 292 adults who’d tested positive for Covid-19 from April to June — including those with both mild and severe cases. They found that two weeks after their diagnosis, 35 percent of people weren’t back to normal, and between the ages of 18 and 34, 20 percent of people reported prolonged symptoms. About half were women, and Hispanic and Black people were overrepresented.

To truly answer the question of who is most at risk, scientists will need to do longitudinal studies tracking large groups of Covid-19 patients with both mild and severe symptoms, for months or even years. These studies would ideally include biologic samples over time as well as self-reported symptoms and medical histories. Then they’ll need to use analysis methods to eliminate confounding factors in order to identify what might put people at risk. 

Although the little research there has been on long Covid has focused on adults, children can also have persistent symptoms. For example, Courtney — a mother in Calgary, Canada, who asked that she and her son be identified by their middle names for the sake of her children’s privacy — can recite the dates and details of her son’s ordeal by heart. “I’ve told this story so many times because we’ve been in and out of the hospital for months,” she says. 

All three of her young children got sick with Covid-19 in early February. One of her 1.5-year-old twins, Alexander, got better — only to get a high fever and full-body rash about a month later. 

Although he wasn’t able to get a Covid-19 test, his infectious disease team and pediatrician now both believe Alexander actually had MIS-C, a rare but severe condition associated with the coronavirus — or possibly long Covid. Since April, he’s been hospitalized three times and to the ER twice more, and continues to have persistent skin lesions, conjunctivitis, and chronic fatigue. He has nightmares from the trauma of visiting the hospital at least once a week for eight months.

“He wakes up screaming, ‘No, no, ow, ow,’” Courtney says. No one can tell her when he might improve. “Just because we don’t have the data that Covid-19 negatively affects babies and children doesn’t mean they are somehow immune.” 

Kate Meredith’s daughter, who’s 12, also got Covid-19, two weeks after Meredith did. While she initially had a mild case, seven months later she continues to have extreme fatigue and tachycardia. On her first day of in-person classes this fall, she fell asleep. “How do you explain that to teachers?” Meredith asks.  

There’s currently little conclusive data on how many children may suffer from persistent symptoms, in part because it’s a population that frequently has mild or no symptoms — making initial testing and later complications like MIS-C more difficult to diagnose. 

Jason, who is studying children’s risk factors for long Covid, says, “If kids don’t recover from an illness, that’s really significant,” adding that long-Covid children will need lots of additional support. “You have to be very concerned that these kids don’t end up continuing a downward cycle of loss and stress.”

Long-Covid patients navigate doubt and difficulty in the medical system

Because symptoms can be varied, long-Covid patients have also had to seek out multiple medical specialists who may not communicate much with one another. 

For example, Meredith still has neurological, pulmonary, and cardiac symptoms. “Should I go see a neurologist?” she asks. “All these smaller symptoms require so much specialized attention.” Even with a positive test, she’s encountered doubt in the doctors she’s turned to.

“Obviously this is uncharted territory for a lot of doctors,” she says. “We just don’t know what’s happening in our bodies.”

Many with long-term symptoms are also having trouble proving they ever had Covid-19, since, due to testing scarcity, many have been unable to get a test.

When Matt Kuzelka got sick in March, he struggled to find somewhere to get tested, while trying to isolate himself from his wife and three kids in their small Brooklyn apartment. When he was finally able to find an opening at a testing center in Manhattan, he asked the center how he was supposed to travel there. “They said, ‘You can take the subway or Uber,’” he recounts, “but I knew I had it. I was like, ‘What about the driver?’ and they said, ‘He’s just going to have to take his chances.’” Kuzelka ultimately decided not to take the risk of exposing anyone else. 

Seven months later, he’s having trouble navigating the additional medical care he now needs, like cardiac MRIs. “It’s been harder to navigate the world of health care needs because I don’t have a positive Covid test.”

For others, their struggle has been complicated by deeper systemic issues. Montano, who has asthma, needed a doctor’s referral in order to get tested in New Jersey in March. But her now ex-primary care physician initially refused to give her one. “He thought I was being theatrical and told me to take a nap,” she says. Less than a week later, Montano was taken to the hospital by ambulance, where she was initially put on supplemental oxygen — but rather than being admitted, she was sent home to her elderly mother without any additional treatment. 

Montano, who describes herself as a light-skinned mixed-race woman, describes a feeling of helplessness in trying to get medical care. “You don’t want to be too vocal, you don’t want to overstep with your family, there’s this facade you want to uphold to save face, and also you have to admit that you’re just human. But how do you admit you’re just human when you’re treated less than human?” she says. In addition to being disproportionately exposed to the virus, Montano says, “Black and Latino communities don’t get treated as timely or as well.” 

“I’m still not sure what the future entails”

To try to help patients get more coordinated care,  several post-Covid care clinics have popped up around the country; one at Mount Sinai initially required a positive Covid-19 test, although it has since opened its criteria. Their waitlist for new patients is now at least six weeks, according to Gothamist.

While patients wait, there’s the added economic and family stress of being sick for so long. “It’s just been this surreal extended medical nightmare for both of us,” Meredith says, adding, “I haven’t even looked at all the bills yet; it terrifies me.” She’s a single mom, and when she was really ill, her daughter — who at one point Meredith had to leave at home alone as she drove herself to the ER — asked, “What happens if you die?” 

“I downplayed it, but I’ve been worried about my future. If I were to have debilitating symptoms, would I have a job left? Would I be able to take care of her?” Meredith pauses. “I’m still not sure what the future entails.”

Because the truth is that because this is an entirely new illness, no one can tell long-Covid patients if they will return to their normal selves, or how long that might take to happen. This makes moving forward into a life shaped by their disease more difficult. 

Especially without a visible illness, Jason says, “Our society does not value people who are sick. If you don’t have a credible, understood illness, you’re basically falling out of the mainstream and in a very vulnerable situation.” 

Lois Parshley is a freelance investigative journalist. Follow her Covid-19 reporting on Twitter @loisparshley.

2020 has been remarkably stressful — from the fear of nuclear war to a presidential impeachment to a pandemic that has killed more than 186,000 Americans as of September 3. And let’s not forget the record unemployment, the school closures, the police killing of George Floyd and other people of color, the months of protests against police brutality and systemic racism, and accelerating climate change.

Many Americans are understandably feeling anxious about this cascade of events — on top of any stressors they may have already been dealing with. “The technical term is, ‘It’s a lot,’” says Linda Goler Blount, president and CEO of the Black Women’s Health Imperative.

A Centers for Disease Control and Prevention survey of 5,412 people in late June found that 31 percent were experiencing symptoms of anxiety and depression, about three times the number of respondents who said the same in the first two quarters of 2019. Another 26 percent reported symptoms of a trauma- or stressor-related disorder. Eleven percent of people said they had seriously considered suicide in the previous 30 days.

Now some researchers are asking if stress — especially chronic stress — might be another preexisting condition that makes Covid-19 infections worse.

Our bodies have evolved to respond in the moment to stressful situations, both physical and emotional. This is often called the “fight-or-flight” response, and it helps us react quickly to danger. But when this becomes a long-term response, these involuntary reactions can be harmful.

There isn’t a single agreed-upon definition of what “chronic” means, though some researchers think stress that persists for weeks or months likely qualifies. Generally, “People thinking about something consistently over time qualifies as a chronic stressor,” says Paula Braveman, director of the Center on Social Disparities in Health at the University of California San Francisco.

Other researchers say an important feature of chronic stress is its instability, of not knowing whether or when the stressor will end. (The pandemic seems to fit the bill.) Still others define it as the body’s inability to return to base level amounts of important hormones, often developing a new, elevated “normal” for stress hormones such as cortisol.

Cortisol is an important part of the stress response, and new research suggests cortisol levels appear to impact the severity of Covid-19. There’s still a lot we don’t understand about the relationship between the two, but clinical trials of a Covid-19 treatment using dexamethasone — a drug that reduces the body’s natural cortisol production, as well as inflammation — has been found to help critically ill patients.

“High levels of cortisol are associated with poor [Covid-19] outcomes, and drugs that block the hormone seem to improve outcomes,” says Kavita Vedhara, a University of Nottingham professor of health psychology who is conducting an ongoing study on Covid-19 and stress. Vedhara says while further research is needed, she wouldn’t be surprised if chronic stress was found to be a risk factor for a severe case of Covid-19. “It fits with what we know about psychological stress generally, and in particular the evidence on stress and other viral infections,” she added.

Understanding how stress impacts Covid-19 could hold clues for preventing or reducing the severity of infections, as well as responding to the inequities that put some racial and minorities groups at greater risk.

Can chronic stress make us more susceptible to infection — and more severe infection?

Fifty years of research on stress suggests it has a profound effect on the body, influencing everything from memory to the way the body stores fat. It’s even been found to cause structural changes in the brain.

In general, “Chronic stress wears the body down,” says Kathryn Freeman Anderson, a sociology professor at the University of Houston. Over time, stress keeps the body locked into a heightened response, resulting in damage somewhat similar to an engine idling for too long.

Prolonged stress also weakens the immune system. In 1991, scientists studying the relationship between psychological stress and immune response intentionally exposed 394 healthy participants to one of five respiratory viruses, including a coronavirus. The subjects were then quarantined and monitored. Even after controlling for factors like age, sex, education, weight, and prior antibody status, the researchers found that a person’s underlying stress levels were associated with an increased risk of getting sick. Since then, dozens of studies have shown that chronic stress increases the risk of not only catching the common cold but also developing conditions such as asthma and Alzheimer’s disease, among others.

Chronic stress can also make vaccines less effective. One study compared the vaccine responses of 32 caregivers of a spouse with dementia — a role associated with chronic stress — against 32 subjects in a control group. After vaccinating both groups against influenza, the researchers found that the caregivers’ stress was associated with a lowered antibody response, meaning less protection against the flu.

Conversely, in 2018, Vedhara designed an experiment for 138 older adults to see whether a positive mood could have a protective effect. For two weeks before and four weeks after their annual flu shot, participants self-reported how they felt using a diary. Vedhara found that psychological influences, including stress and mood, influenced participants’ antibody response. (Stress responses are often measured by observing specific emotional states.)

Vedhara found that if participants felt unstressed and upbeat, particularly on the day they were vaccinated, the vaccine worked better. The effect on antibody production was about as large as the effect of statins on cardiovascular events. “These are very tangible, very profound effects,” Vedhara says.

Similar results have also been seen in young people: A 2018 study of 83 undergraduates found that people with a positive affect — feelings of happiness and positivity — had better antibody responses to a vaccination. Affects, or observable emotions, are impacted by stress, both for better and worse.

One study found that people who had a negative affect in response to daily stressors over the course of a week — meaning they don’t recover well from daily stress — had poorer physical health in the long term. Another study of 8,542 participants found that a positive affect not only helped reduce the damaging effects of stress but was also associated with lower mortality rates. Further research is needed into what actually causes these differences. It may be for both behavioral and neurobiological reasons; when stressed, people might behave in ways that hurt the immune system, such as by drinking alcohol or not getting enough sleep.

But stress also influences the concentration of many hormones, including cortisol, that impact the production of antibodies. During the fight-or-flight response, the brain activates a network that includes the pituitary and adrenal glands. These glands release cortisol and other hormones that keep the body on high alert. But cortisol also turns out to have a surprising place in the immune system: Most immune cells also have a receptor for it. “This means there’s a direct mechanism by which cortisol can regulate immune cells and our immune system,” Vedhara says.

When people have chronically high levels of cortisol from being stressed, they end up with lots of inflammatory cytokines. High levels of cytokines have also been noted in severe cases of Covid-19, as have lower levels of lymphocytes, the white blood cells that help fight infections.

Scientists are looking for other direct relationships between chronic stress and Covid-19. Besides cortisol, other important hormones, including one called Ang-II, are impacted by stress; elevated levels of Ang-II have already been associated with severe Covid-19 cases.

Stress is distributed unequally — and for many, it’s exacerbated by systemic racism

Although most of us have experienced more stress this year, chronic stress, like so much else, tends to affect some individuals, like people of color, more than others.

In April, during the early stages of Covid-19, Vedhara found that Black, Asian, and other ethnic minorities in the UK reported feeling more stressed than white people, even after accounting for age, gender, and working situation. These same communities also reported disproportionate deaths from Covid-19.

According to CDC data, Black, Native American, and Latino people all have age-adjusted hospitalization rates around 4.7 times higher than the rate of white people. A Black person with Covid-19 is almost four times more likely than a white person to die from it.

Goler Blount says it’s frustrating that the data is often reported without context. “It’s not because they’re Black, it’s because of the experience of being Black,” Goler Blount says.

“Discrimination doesn’t stay in the realm of mental health,” says Anderson. “We can actually measure the physical impact on the body.” In the 1990s, public health researcher Arline Geronimus studied what the experience of racism does to the body and found that “racial inequalities not explained by poverty existed across a range of biological systems.” She called the health consequences of the large and small stresses caused by racism “weathering” — and this kind of erosion is more than a metaphor.

Multiple studies show that an experience of discrimination increases cortisol levels, and the effects accumulate over a lifetime.

Chronic stress can start damaging health and affecting gene expression even before birth. A number of studies have linked stress with shorter telomeres, a protective casing at the end of DNA strands that is diminished each time a cell divides. Shortened telomeres have been linked to increased disease and shorter lifespan.

Though telomeres can be repaired by an enzyme called telomerase, stress and cortisol exposure reduces the body’s supply of the enzyme. One study found that the higher a mother’s prenatal anxiety, the shorter her baby’s telomeres were, raising questions about whether stress risks can be inherited. If true, this might amplify the disproportionate effect chronic stress has on people of color.

Another line of research has shown that if young people experience systemic discrimination, it can trigger higher levels of cytokines, magnifying the impact of future stress on their health. A study by the Yale School of Public Health found that by middle age, women who had frequent experiences with discrimination had significantly higher levels of visceral fat, putting them at higher risk for serious conditions such as heart disease and diabetes (two risk factors for severe Covid-19). In older adults, stress changes the levels of hormones involved with blood pressure and contribute to hypertension, another risk factor for Covid-19.

It’s not just the experience of discrimination, but also the fear and anticipation of racism that cause harm. “The vigilance, the concern itself is a strain on the body,” says Brenda Major, a professor and social psychologist at the University of California Santa Barbara. She says the recent videos and other coverage of police killings and protests against police brutality are themselves a source of stress. “Reading about people like you being shot and killed can itself heighten concern, fear, and vigilance,” says Major.

UCSF’s Braveman says chronic stress is also structural, tied to “how we track people into unhealthy places and expose them to unhealthy conditions over their lifetimes.” She says the US culture perpetuates racism — and its stress — even when there is not a particular individual intending to discriminate.

We don’t have to look far for examples of how communities of color are disproportionately exposed to environmental pollutants like cancer-causing chemicals and fine particulate matter that can cause respiratory illnesses, as well as a higher risk of natural disasters —environments that are often sources of stress themselves, as well as an indirect stress when friends and family become ill. “This is literally the environmental impact on us, and it’s how our bodies are responding,” says Goler Blount.

How to leverage what we know about stress to decrease it — and Covid-19 risk

To better understand how stress — both recent and long-term — might be impacting individuals’ risk for Covid-19, many researchers are conducting experiments.

Following up on her April survey of almost 4,000 people in the UK and New Zealand, Vedhara is now asking participants to send in a small hair sample. She’ll use this to measure cortisol, investigating how self-reported mental health over the course of the pandemic results in measurable physical changes. She’ll also look to see whether cortisol levels are associated with being infected with Covid-19 — and the severity of illness.

Already, other research suggests that cortisol is tied to worse Covid-19 outcomes. In a recent study of 535 people published in The Lancet, those with confirmed cases of Covid-19 had much higher levels of cortisol than those who did not. After taking measurements within 48 hours of being admitted to the hospital, the scientists found a doubling of cortisol concentration was associated with a 42 percent increase in mortality.

More research is needed, but in the meantime, Vedhara notes while the known risk factors for severe Covid-19 cases — age, ethnicity, and preexisting conditions — are largely out of our control, there are ways to improve mental health. We don’t know yet how much reducing stress might help protect against severe Covid-19, but there may be measures that can be used now to reduce anxiety overall.

Understanding the source of stress can be helpful in figuring out how to manage it. “The first step is to understand what is giving rise to those negative feelings,” Vedhara says. Some stress is emotion-focused — like the ongoing uncertainty of when the pandemic will end — and can be reduced through skills like mindfulness. For instance, when patients with colorectal cancer meditated at the beginning of chemotherapy treatments, it improved their cortisol response.

But changing personal behavior cannot combat structural sources of stress. (Meditation is certainly not a cure for the stress of systemic discrimination.)

“One of the most striking features of [self-reported stress in April],” Vedhara says, is that it was strongly related to “how much people were worried about contracting Covid-19.”

A recent study suggests the high numbers of Black, Latinx, and Asian people dying from Covid-19 might actually be an underestimate. Goler Blount says a Black Women’s Health Imperative analysis found that in the next three years, every Black person in the US will lose someone they know to Covid-19 or its long-term consequences. Vedhara suggests this demonstrates a need for more effective public health interventions, rather than psychological ones.

As the pandemic continues to take thousands of American lives each day — and as other economic, safety, and logistical stresses mount — Goler Blount says stress is only accumulating. “All these things are connected. We are here, all in the middle of this, grieving.”

Lois Parshley is a freelance investigative journalist. Follow her Covid-19 reporting on Twitter @loisparshley.

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Though 33 states now have face mask mandates, Gov. Pete Ricketts says his state of Nebraska will not be joining them. On Monday, Ricketts doubled down on his conviction that a statewide mask mandate would be too “heavy-handed.”

“I don’t want to make it a crime,” he said at a press conference.

Ricketts’s resistance comes as his office is challenging mask ordinances in Lincoln and Lancaster County that have already gone into effect. Teachers’ unions, meanwhile, have called his failure to pass a statewide mask order a “dereliction of duty.”

“I would die for my students. Please don’t make me,” read a teacher’s sign at a recent protest across from Ricketts’s office.

Though the science on the effectiveness of masks for reducing the spread of the coronavirus is more established now than it was early in the pandemic, mandatory masking is still a new and contentious idea. Public health experts and unions are calling for a national mandate to protect the most vulnerable, but President Donald Trump has said he opposes it, telling CNN, “No, I want people to have a certain freedom, and I don’t believe in that, no.”

Popular support for mask-wearing is growing: A Hill-HarrisX poll conducted from July 26-27 found that 82 percent of Americans would support a national mask mandate. Yet mask-wearing has also been correlated with partisan identity, and many Americans still refuse to wear them in indoor public settings such as grocery stores, even in states and cities where mandates are in place. Some are even using fake exemption cards to try to get out of wearing a mask where it is now required.

As consensus grows on the urgency of widespread mask use to slow a raging national health crisis, policymakers are finding that mandates may be helpful but not entirely sufficient. Perhaps unsurprisingly, enforcement — whether by local officials, police, or employees of airlines or retailers — is proving challenging. Meanwhile, lessons from other health campaigns, including seatbelts, condoms, and texting while driving, suggest that public education is just as important if you actually want people to change their behavior.

The science behind masks and mask mandates keeps getting stronger

People can spread SARS-CoV-2 before they know they are sick, and masks help contain the large respiratory droplets that transmit the virus. This primarily helps prevent an infected person — even if they don’t have symptoms — from spreading the virus to others. Increasing evidence shows that masks may help protect wearers from breathing in aerosols, too.

In July, the Centers for Disease Control and Prevention (CDC) affirmed its guidance that “cloth face coverings are a critical tool in the fight against COVID-19 that could reduce the spread of the disease.” The agency advises that anyone over the age of 2 should wear a face covering that goes over their nose and mouth in public, as well as around people who do not live in their household.

A study published in June in the journal Health Affairs, which looked at 15 states and the District of Columbia before and after their mask mandates, found that masks reduced new Covid-19 cases, particularly over time. In the first five days after masks were required, new cases slowed by almost 1 percentage point; at three weeks, it was 2 percentage points. That may not sound like much, but it adds up. Another study looking at coronavirus deaths in 198 countries found that countries “with cultural norms or government policies supporting public mask-wearing” had far fewer deaths.

Goldman Sachs has modeled the impact of a national mask mandate, and its analysis suggested that such an order could not only reduce the number of coronavirus cases but also prevent a 5 percent loss in GDP when used in place of lockdowns. Many other countries — including the UK, where mask use was initially controversial — have issued national mask mandates. Germany, for example, has required masks since April.

States are trying to make mask mandates stick with fines and jail time

Many cities and states have decided to issue mask mandates, giving them the legal authority to prosecute people who don’t comply.

New Jersey was the first state to mandate mask-wearing indoors. It did so back on April 8, when the state, along with New York, was grappling with a massive wave of cases. The order required customers and staff to wear face coverings at essential businesses and on public transit, and said businesses could deny entry to customers who refused to wear them.

In July, the order was extended to wearing masks outside when social distancing isn’t possible, although the governor has not said how it will be enforced. The focus was initially on education, with volunteers in Newark passing out fliers, but later that month, the city’s police department announced it would begin handing summonses to anyone who did not comply.

In Colorado, both Denver and Boulder County adopted mask policies in May, which was notable both for the early timing and for the steep penalties right off the bat for breaking them. In Boulder County, if you refuse to wear a mask in indoor and outdoor public spaces when you can’t stay 6 feet from others, you face up to a $5,000 fine and one year in jail; in Denver, it’s up to $999 or 300 days in jail. (Other countries, like Germany, are levying even heavier fines: Failing to comply with mask use there can lead to a fine of 10,000 euros, which is around $11,755 USD.) Two months after those county-level mandates, Colorado’s governor issued a statewide mask order, which specified that counties and cities in the state are allowed to enforce even stricter rules. Denver, for example, requires children over the age of 3 to wear masks; the state requires only children over 11 to do so.

As Colorado’s cases increased through late July, Danica Lee, director of public health investigations at the Denver Department of Public Health & Environment, says that getting people to wear masks became a little easier, with people recognizing the higher risk of becoming infected. Lee has been one of the top health officials in charge of Denver’s Covid-19 response, including finding the balance between educating the public on the importance of wearing masks and punishing those who refuse to comply.

“So far, we’ve been saving enforcement for truly egregious situations,” she says. But the department is switching up its tactics: It now has its own enforcement teams, which are currently focusing on night and weekend compliance. “At first, we focused on trying to encourage people to not be out socializing in public. Over the past few weeks, we’ve had an increased focus on compliance with businesses, as well as individuals,” Lee says. As of July 30, the department had issued 809 mask-related warnings.

In the last week of July, the department went from a total of seven mask citations to 27, the majority of which were issued at bars and restaurants, and predominantly to management rather than to patrons. These people have been given a court summons, and a judge will determine the fine amount or duration of jail time. The first weekend of August, teams in Denver issued 20 tickets for violations of public health orders, including not wearing face coverings or exceeding crowd capacities. Inspection teams also closed five businesses that were previously warned or had particularly egregious violations.

Lee recognizes that it can be hard for businesses to enforce Denver’s guidelines. The department has been advising business owners to clearly post signs about wearing masks and ensure that their own employees do. “Basically, we’re advising taking all the measures you can, short of intervening with individuals, because there were quite a few safety concerns over interactions becoming politicized,” Lee says. “Any time there is a conflict with a patron that looks like it could pose safety hazards, our guidance would be to contact law enforcement.”

Laws can also be difficult to enforce universally and equitably, says Julia Marcus, an infectious disease epidemiologist and an assistant professor at Harvard Medical School.

In one example, during a weekend in May, the New York Police Department handed out masks to white people in affluent neighborhoods while officers punched a Black man and issued tickets to other people of color for not wearing masks. At the beginning of mask orders, some worried that racism would make it unsafe for people of color to cover their faces, like in a viral video of two Black men in surgical masks being tailed around a store by a policeman. Now we are seeing that the opposite problem — being unfairly singled out for not wearing a mask — may also be an issue. 

In the absence of state mandates, corporate mask rules fall on employees to enforce

Many retailers, worried about their high-risk indoor environments, haven’t waited for government orders to require clients to wear masks. Major chains, including CVS, Target, Walmart, McDonald’s, Kroger grocery stores, and Costco, have announced nationwide mask policies, even in places without a statewide order, like Arizona and Florida.

Home Depot, which rolled out a country-wide mask order on July 17, says it has put up signs warning customers and plays announcements over the PA systems. “We also have social distancing captains who will remind customers that they must wear a mask,” a company spokesperson wrote in an email. Home Depot will offer masks to those who arrive without one. 

But these mandates also come with limitations. “It’s too dangerous to forcibly or physically deny entry,” the Home Depot spokesperson wrote.

These aren’t idle fears: In San Antonio, a passenger was shot after a man was told he couldn’t ride a public bus without a mask. A Dollar Store employee in Michigan was killed after telling a customer to wear a mask. And employees at a Trader Joe’s in Manhattan were taken to the hospital after a fight with customers who refused to wear masks.

A spokesperson for a major retailer, who asked not to be named because he didn’t have permission from his employer to speak with the media, said businesses just haven’t gotten the support they need from government and law enforcement to enforce mask policies. “There are [customers] who are just being stubborn now, and we’re trying to keep our employees safe,” he told Vox. He says when the company has called law enforcement for help, some stores have gotten the cold shoulder. “They’re like, ‘Don’t call us for a mask policy, it’s a waste of our time. We’re not coming.’ Which is fine, I get it. But if city officials are telling us we have to do it, and there’s no enforcement mechanism … the last thing we want to do is to have our employees physically engage anyone — over any activity.”

Airlines, on the other hand, have had some success in enforcing their mask requirements. A Delta flight was recently forced to return to its gate after two passengers refused to comply with its mask policy. The airline warned that violations of its mask requirement might result in the loss of future travel privileges.  

Alaska Airlines requires during check-in that people agree to wear a mask, and it provides masks on request for people who don’t have one. If passengers refuse to wear one, flight attendants have been given the authority to give passengers a “yellow card” warning, like in soccer, and then ban repeat offenders from future travel. American Airlines recently removed from the plane a woman who refused to wear a mask — and the other passengers clapped. 

Other sectors of the travel industry are taking note: The American Hotel & Lodging Association, whose members include Hilton, Hyatt, Marriott, Radisson, and Wyndham, recently started requiring staff and guests to wear face masks regardless of state policy. The specific rules will vary by company, and how this will be enforced hasn’t been made clear. Chip Rogers, president and CEO of the association, said in an emailed statement that many companies have already been instituting mask rules, which helps staff and guests “to make it safer and easier for Americans to travel, while also supporting hotel and tourism employees.”

And as schools reopen, they may become ground zero for mask enforcement fights. In Indiana, for example, Gov. Eric Holcomb recently made a state-wide mandatory mask order for everyone, including all students in third grade and above. “Kids should not be getting mixed messages throughout the day,” Holcomb said in a press conference. “When they leave school grounds, they need to see that everyone is doing what they’re doing — that best practices are best for all.” 

To help make this mandate stick, Indiana has purchased 3.1 million masks to distribute to students. Holcomb reportedly wanted to have breaking the mandate punishable as a class B misdemeanor, but after significant pressure, the order says that schools will be responsible for developing and implementing an enforcement plan. States like Nebraska lacking statewide mandates may soon see differing mask rules in schools, depending on their location. That makes it harder for public health officials like Lee in Colorado, who says that in her experience, “it’s really important to have consistent messages between health agencies” at the local and state levels. 

Shifting norms around masks to reduce the anger and the shame

Many public health experts say that consistent public health education and effective messaging is the most important tool in getting people to change their behavior. Which means that threatening people with being banned from a business or issuing fines or jail time are not actually the best ways to get more people to wear masks in public. 

“As much as we can shift social norms around wearing masks so that there will be fewer angry people who refuse to wear them — that would be best,” Marcus says.  

According to Marcus, the AIDS epidemic is an excellent example of the perils of criminalization. There are laws in 26 states around the country that make it illegal to not disclose if you are HIV positive before having sex, but they have only increased stigma and abuse. “The way I see it, it’s all on a spectrum — shaming and fines and arrests, it’s all the same punitive model,” she says. 

“Ideally, we would have a model that promotes collective action through rewards and positive reinforcement,” Marcus says. The Surgeon General recently modeled an example of what that would look like, telling the president at an event: “You look badass in a facemask.”

Thus far, the mixed mask messaging from government leaders — and even evolving recommendations from health agencies — hasn’t helped unify people around this effective public health action. It can understandably be hard for residents to embrace this sort of new behavior when even their local officials can’t agree on it. 

For example, in Georgia, where Atlanta’s mayor, Keisha Lance Bottom — who herself has tested positive for Covid-19 — tried to create a mask mandate. The governor sued to try to block the mandate in court (“on behalf of the Atlanta business owners and their hardworking employees who are struggling to survive”). 

“The main problem with masks now is the lack of a coherent message from the leaders,” says Alex Horenstein, an assistant professor of economics at Miami Herbert Business School at the University of Miami, who studies behavioral economics. He says that this leads to inaccurately assessing the risk of not wearing a mask “since the signal is too noisy,” adding that if more people do not wear masks, the risk aggregates, making those who do less safe too — and possibly leading people to the false conclusion that masks don’t work.  

Marcus has found that in conversations with people who are ideologically opposed to masks that they are surprisingly willing “to listen to a scientist when that scientist doesn’t shame them or yell at them for their risky behavior.” 

Instead, she tries to acknowledge their concerns — like that masks aren’t effective or that masks infringe on their liberties. From there, they can have a conversation about these issues, talking about how masks are more important in certain settings or about other people’s freedom when distancing isn’t an option. “This is what public health does,” Marcus says. “We try to understand what’s making it hard and then adopt strategies to increase adherence.” 

It’s also entirely normal for there to be resistance to a public health intervention, says Horenstein. “People want to have a choice over how much risk they want to face,” he says. “If you make a regulation that constrains people’s choices too much, what happens is they change their behavior so they can still approach their optimal risk.”

Like Marcus, Horenstein says the best answer is public education, tailored to specific audiences’ risks and values. Yet, he adds, risks, at the end of the day, are collective. “So the question we’re facing with masks is: What risk should we let people take when their decisions affect others?”

Lois Parshley is a freelance investigative journalist. Follow her Covid-19 reporting on Twitter @loisparshley.