2022.06.15 长期的COVID可能是一个 "大规模恶化事件

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Long COVID Could Be a ‘Mass Deterioration Event’
A tidal wave of chronic illness could leave millions of people incrementally worse off.

By Benjamin Mazer
Fractured photo-collage of a woman in seeming discomfort
The Atlantic; Getty
JUNE 15, 2022, 12:02 PM ET
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In late summer 2021, during the Delta wave of the coronavirus pandemic, the American Academy of Physical Medicine and Rehabilitation issued a disturbing wake-up call: According to its calculations, more than 11 million Americans were already experiencing long COVID. The academy’s dashboard has been updated daily ever since, and now pegs that number at 25 million.

Even this may be a major undercount. The dashboard calculation assumes that 30 percent of COVID patients will develop lasting symptoms, then applies that rate to the 85 million confirmed cases on the books. Many infections are not reported, though, and blood antibody tests suggest that 187 million Americans had gotten the virus by February 2022. (Many more have been infected since.) If the same proportion of chronic illness holds, the country should now have at least 56 million long-COVID patients. That’s one for every six Americans.


So much about long COVID remains mysterious: The condition is hard to study, difficult to predict, and variously defined to include a disorienting range and severity of symptoms. But the numbers above imply ubiquity—a new plait in the fabric of society. As many as 50 million Americans are lactose intolerant. A similar number have acne, allergies, hearing loss, or chronic pain. Think of all the people you know personally who experience one of these conditions. Now consider what it would mean for a similar number to have long COVID: Instead of having blemishes, a runny nose, or soy milk in the fridge, they might have difficulty breathing, overwhelming fatigue, or deadly blood clots. Even if that 30 percent estimate is too high—even if the true rate at which people develop post-acute symptoms were more like 10 or 5 or even 2 percent, as other research suggests—the total number of patients would still be staggering, many millions nationwide. As experts and advocates have observed, the emergence of long COVID would best be understood as a “mass disabling event” of historic proportions, with the health-care system struggling to absorb an influx of infirmity, and economic growth blunted for years to come.

Indeed, if—as these numbers suggest—one in six Americans already has long COVID, then a tidal wave of suffering should be crashing down at this very moment, all around us. Yet while we know a lot about COVID’s lasting toll on individuals, through clearly documented accounts of its life-altering effects, the aggregate damage from this wave of chronic illness across the population remains largely unseen. Why is that?

A natural place to look for a mass disabling event would be in official disability claims—the applications made to the federal government in hopes of getting financial support and access to health insurance. Have those gone up in the age of long COVID?

In 2010, field offices for the Social Security Administration received close to 3 million applications for disability assistance. The number dropped off at a steady rate in the years that followed, as the population of working-age adults declined and the economy improved after the Great Recession, down to just about 2 million in 2019. Then came COVID. In 2020 and 2021, one-third of all Americans became infected with SARS-CoV-2, and a significant portion of those people developed chronic symptoms. Yet the number of applications for disability benefits did not increase. In fact, since the start of the pandemic, disability claims have dropped by 10 percent overall, a rate of decline that matches up almost exactly with the one present throughout the 2010s.

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“You see absolutely no reaction at all to the COVID crisis,” Nicole Maestas, an associate professor of health-care policy at Harvard, told me. She and other economists have been looking for signs of the pandemic’s effect on disability applications. At first, they expected to see an abrupt U-turn in the number of applications after the economy buckled in March 2020—just as had happened in the aftermath of prior recessions—and then perhaps a slower, continuous rise as the toll of long COVID became apparent. But so far, the data haven’t borne this out.

That doesn’t mean that the mass disabling event never happened. Social Security field offices were closed for two years, from March 17, 2020, to April 7, 2022; as a result, all applications for disability benefits had to be done online or by phone. That alone could explain why some claims haven’t yet been filed, Maestas told me. When field offices close, potential applicants have less support available to help them complete paperwork, and some give up. Even now, with many federal offices having reopened, long-haulers may be struggling more than other applicants to navigate a bureaucratic process that lasts months. Long COVID has little historical precedent and no diagnostic test, yet patients must build up enough medical documentation to prove that they are likely to remain impaired for at least a year.

Read: The pandemic after the pandemic

In light of all these challenges, federal disability claims could end up as a lagging indicator of long COVID’s toll, in the same way that COVID hospitalizations and deaths show up only weeks after infections surge. Yet the numbers we have so far don’t really fit that explanation. The Social Security Administration told me last week that the federal government had received a total of 28,800 disability claims since the start of the pandemic that make any mention whatsoever of the applicant having been sick with COVID. This amounts to just 1 percent of the applications received during that time, by the government’s calculation, and would represent an even tinier sliver of the total number of long-COVID cases estimated overall. When I passed along this information to Maestas, she seemed at a loss for words. After a pause, she said: “It’s just not a mass disabling event from that perspective.”

The National Health Interview Survey provides another perspective, though the population effects of long COVID are no easier to find in those data. The survey, performed annually by the federal government, measures disability rates among Americans by asking whether they have, at minimum, “a lot of difficulty” completing any of a set of basic tasks, which include concentrating, remembering, walking, and climbing stairs. The proportion of people who reported such difficulties was flat through 2021: 9.6 percent of adults were disabled in December 2019, as compared with 9.5 percent two years later.

Graph of SSA disability applications and CPS survey data from 2012 to 2022
Other sources of disability data do hint—but only hint—at long COVID’s consequences. When the U.S. Bureau of Labor Statistics performs its monthly employment survey, it asks Americans a few basic questions about their physical and cognitive health, including whether they have difficulties concentrating, making decisions, walking, or running errands. By this measure, the number of people reporting such problems began to nudge upward by the middle of 2021. (Disability rates briefly appeared to decline at the start of the pandemic, when in-person interviewing went on hold.) But this increase, from about 7.5 to 8 percent of the working-age population, represents a tiny blip compared with the extrapolated number of Americans who have long COVID, and most of this new cohort is still able to work. Maestas suspects that these particular disability numbers represent the first sign of a true upswing. “As you watch them keep going up each quarter, it’s starting to look like maybe there is something going on,” she said.

The survey measures described above may be affected slightly by the pandemic’s disproportionate death toll among already disabled people. They could also only ever tell one part of the story. At best, they’ll capture a certain kind of long COVID—the sort that leads to brain fog, fatigue, and weakness, among other severe impairments in memory, concentration, and mobility. One of the overarching problems here is that long COVID has been associated with many other ailments, too, such as internal tremors, sudden heart palpitations, and severe allergic reactions. None of these issues is likely to show up in the NHIS or BLS data, let alone qualify someone for long-term financial support from the Social Security Administration.

If the “mass disabling event” plays out as tens of millions of cases of shooting nerve pain or diarrhea, for example, or even just a persistent loss of smell, then you might never see a large jump in the number of Americans who report having difficulty functioning. In that case, though, more Americans might end up seeking out their doctors for evaluations, tests, and treatments. A growing number of symptoms, overall, should lead to a growing burden, overall, on the country’s health-care system.

The available data suggest that the opposite is true, at least for now. A report from Kaiser Family Foundation, released last fall, found that both outpatient and inpatient health-care spending was actually lower than projected through the first half of 2021—even accounting for millions of acutely ill COVID patients. “We have not seen pent-up demand from delayed or forgone care,” the nonprofit wrote. (This modest spending was recorded despite the fact that the proportion of Americans with health insurance increased during the first two years of the pandemic.) In February, the consulting firm McKinsey surveyed leaders from 101 hospitals around the country, who said that outpatient visits and surgeries were still below pre-pandemic levels. The pandemic’s effect on health-care workers must be contributing to this decline in volume, but it can’t account for all of it. Most patients can still snag a specialist appointment within two or three weeks, according to McKinsey’s data.


It’s possible that many long-haulers have simply given up on getting medical care, because they’ve understandably concluded that treatments don’t exist or that doctors won’t believe they're sick. (The scarcity of clinics dedicated to patients with long COVID could also be a problem.) The U.K.’s Office for National Statistics has been performing one of the world’s largest long-COVID surveys, in an effort to measure the full extent of this behind-the-scenes suffering. The study shows that, as of the beginning of May, 3 percent of that country’s residents identify as having long COVID, broadly defined as “still experiencing [any] symptoms” more than four weeks after first getting sick. (Eighty percent of the U.K. population is estimated to have been infected with the coronavirus at least once.) About two-thirds of this group—amounting to more than 1 million people—say that the condition affects their ability to perform day-to-day activities. Among the survey’s most-cited chronic symptoms are weakness, shortness of breath, difficulty concentrating, muscle aches, and headaches.

Read: Being Black and disabled is a constant struggle

In its focus on persistent symptoms, the U.K. survey may be leaving out other, more insidious consequences of COVID. A CDC analysis, published last month, examined the medical records from hundreds of thousands of adult COVID patients, and concluded that at least one in five might experience post-illness complications. Some of these were of the familiar types (trouble breathing, muscle pain); others were of the ticking-time-bomb variety, including blood clots, kidney failure, and heart attacks. This study’s methods have been harshly criticized—people who have long COVID “deserve better, much better,” Walid Gellad, a professor of medicine at the University of Pittsburgh, told me—and the one-in-five statistic could be way too high. But if the CDC’s results are correct in substance—if various mortal dangers do increase by a significant degree after COVID—then the effects of these should also be detectable at the population level. Comparisons between individual study results and overall disease burden offer a reality check for extreme findings, Jason Abaluck, an economist and a health-policy expert at Yale, told me. “They allow you to put bounds on things.”


Where does that leave us with long COVID? The majority of Americans have already encountered the virus, many more than once. The CDC suggests that these people will, on average, experience about a 50 percent increase in their respective risks of blood clots, kidney failure, and heart attacks, as well as diabetes and asthma. Comprehensive national disease estimates will take years to compile, but provisional rates of death from heart disease, stroke, and kidney disease haven’t really budged since 2019, and the NHIS survey has shown no increase in the number of Americans with high blood pressure or asthma.

In short, here’s what we can say right now: Disability rates might be rising, but only by a little bit; the health-care system seems to be coping; deaths from post-COVID complications aren’t mounting; and the labor force is holding up. Long COVID, in other words, isn’t yet standing out amid the pandemic’s other social upheavals.

Liza Fisher has long COVID, and she shows up in the data. The 38-year-old former flight attendant and yoga instructor from Houston became ill with COVID in June 2020. Her infection led to months of hospitalizations, procedures, and rehabilitation. She now requires a team of medical specialists, and she remains severely limited in her daily activities because of neurological symptoms, fatigue, and allergic reactions. Fisher went on medical leave from work after her symptoms began, and she never returned. In December 2020, she applied for disability benefits from the Social Security Administration, and was granted them about six months later.


“Government numbers aren’t accurate, and may never be accurate,” Fisher told me. She knows of long-haulers who have applied for disability programs under better-established diagnoses, for instance, because they believed that citing long COVID wouldn’t grant them access. And she said that when national metrics don’t reflect the everyday reality of the long-COVID community, advocating for research, treatment, and support services becomes more difficult.

Read: The promising treatment for long COVID we’re not even trying

Frank Ziegler also has long COVID, but he hasn’t quit his job, nor has he put in a claim for any benefits. A 58-year-old lawyer from Nashville, Tennessee, Ziegler developed a mild case of COVID in January 2021. The nasal congestion he experienced was so unremarkable that he assumed at first he had a simple sinus infection. But in the course of his recovery, something about Ziegler’s appetite changed—seemingly for good. Foods he had previously loved became strangely unappetizing; he lost a significant amount of weight. Then he started noticing hand tremors, trouble breathing, and cognitive issues. A battery of medical tests came back essentially normal, but Ziegler still doesn’t feel as well as he did before catching the virus. His life has changed, but that difference might not be reflected on any government graph. “The square pegs of long-COVID patients are never going to fit into the round holes of conventional testing,” he told me.


The mix of symptoms and experiences that define long COVID suggests that no single measure, or group of measures, can illustrate the suffering of long-haulers in aggregate. A “mass disabling event” is not playing out in the data we have. That could change in the months and years to come, or else it might indicate that we’re in another kind of moment, one that leaves tens of millions of Americans feeling somewhat worse off than they were before, not so sick that they can’t hold down a job or need medical attention, but also not quite back to baseline. Call it a “mass deterioration event.”

“There are a significant number of people that can’t simply move on,” Ziegler told me. “Many of them have no idea why they are feeling the way they do, and they have not been able to get any relief.” That form of epidemic—one that degrades quality of life, incrementally, for millions—is likely unfolding, even as a much smaller group of patients, including Fisher, see their lives utterly transformed by chronic illness. We don’t know how bad the long-COVID crisis will get, but for many, there’s no turning back.

Benjamin Mazer is a physician specializing in laboratory medicine.




长期的COVID可能是一个 "大规模恶化事件
慢性疾病的浪潮可能会使数百万人的情况逐渐恶化。

本杰明-马泽尔报道
一个看起来很不舒服的女人的断裂照片拼贴画
大西洋报》；盖蒂
2022年6月15日，美国东部时间下午12:02
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2021年夏末，在冠状病毒大流行的三角洲浪潮中，美国物理医学和康复学会发出了令人不安的警讯。根据其计算，超过1100万美国人已经在经历漫长的COVID。此后，该学院的仪表板每天都在更新，现在将这个数字定为2500万。

即使这可能是一个重大的低估。仪表板的计算假设30%的COVID患者会出现持久的症状，然后将这一比率应用于账面上的8500万确认病例。然而，许多感染没有被报告，血液抗体测试表明，到2022年2月，有1.87亿美国人感染了这种病毒。(如果慢性病的比例不变，那么这个国家现在应该至少有5600万长期感染病毒的病人。这相当于每六个美国人中就有一个。


关于长COVID的很多东西仍然很神秘：这种情况很难研究，很难预测，而且有不同的定义，包括令人迷惑的症状范围和严重程度。但是上面的数字意味着无处不在--社会结构中的一条新辫子。多达5000万美国人有乳糖不耐症。类似数量的人有痤疮、过敏、听力损失或慢性疼痛。想一想你认识的所有经历这些情况之一的人。现在考虑一下，对于类似数量的人来说，长COVID意味着什么：他们可能不会有斑点、流鼻涕或冰箱里的豆浆，而是有呼吸困难、压倒性的疲劳或致命的血凝块。即使这个30%的估计太高，即使人们出现急性病后症状的真实比率更像是10%或5%，甚至2%，正如其他研究表明的那样，患者的总数仍将是惊人的，全国有数百万人。正如专家和倡导者所观察到的那样，长期COVID的出现最好被理解为一个历史性的 "大规模致残事件"，医疗保健系统将努力吸收大量的疾病涌入，经济增长将在未来几年受到影响。

事实上，如果--正如这些数字所表明的那样，每六个美国人中就有一个人已经患有长型COVID，那么此时此刻，在我们周围，应该有一股痛苦的浪潮扑面而来。然而，虽然我们知道很多关于COVID对个人的持久伤害，通过对其改变生活的影响的明确记录，但这一波慢性疾病对整个人口的总体损害仍然在很大程度上没有被看到。这是为什么呢？

寻找大规模致残事件的一个自然的地方是官方的残疾申请--向联邦政府提出的希望获得财政支持和医疗保险的申请。在漫长的COVID时代，这些申请上升了吗？

2010年，社会安全局的外地办事处收到近300万份残疾援助申请。在随后的几年里，随着劳动年龄人口的减少和大衰退后经济的改善，这个数字以稳定的速度下降，到2019年仅为200万左右。然后出现了COVID。在2020年和2021年，三分之一的美国人感染了SARS-CoV-2，这些人中有相当一部分出现了慢性症状。然而，申请残疾津贴的人数并没有增加。事实上，自大流行开始以来，残疾申请总体上下降了10%，这一下降速度几乎与整个2010年代存在的下降速度完全吻合。

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"你完全看不到对COVID危机的反应，"哈佛大学卫生保健政策副教授妮可-梅斯塔斯告诉我。她和其他经济学家一直在寻找这种大流行病对残疾申请的影响的迹象。起初，他们预计在2020年3月经济下滑后，申请数量会突然掉头--就像以前的经济衰退后发生的那样--然后也许会随着长期COVID的损失变得明显，出现缓慢的持续上升。但到目前为止，数据并没有证明这一点。

这并不意味着大规模致残事件从未发生。社会保障局外地办事处从2020年3月17日到2022年4月7日关闭两年；因此，所有残疾福利的申请都必须在网上或通过电话进行。Maestas告诉我，仅这一点就可以解释为什么有些申请还没有被提交。当外地办事处关闭时，潜在的申请人得到的帮助较少，无法帮助他们完成文书工作，有些人就放弃了。即使是现在，许多联邦办事处已经重新开放，长工们可能比其他申请人更难驾驭一个持续数月的官僚程序。长途COVID没有什么历史先例，也没有诊断测试，但患者必须建立足够的医疗文件，以证明他们有可能在至少一年内保持受损状态。

阅读。大流行之后的大流行

鉴于所有这些挑战，联邦残疾索赔最终可能成为COVID长期损失的一个滞后指标，就像COVID住院和死亡人数在感染激增后几周才显示出来一样。然而，到目前为止，我们掌握的数字并不真正符合这种解释。社会安全局上周告诉我，自大流行开始以来，联邦政府总共收到了28,800份残疾申请，其中提到了申请人曾患过COVID。根据政府的计算，这只相当于在此期间收到的申请的1%，而且在估计的长期COVID病例总数中，这只占很小的一部分。当我把这些信息传递给梅斯塔斯时，她似乎不知所措。停顿了一下，她说。"从这个角度来看，它只是不属于大规模致残事件。"

国家健康访谈调查提供了另一个角度，尽管在这些数据中不容易发现长期COVID的人口效应。这项调查由联邦政府每年进行，通过询问美国人在完成一系列基本任务时是否至少有 "很大的困难 "来衡量他们的残疾率，这些任务包括集中注意力、记忆、行走和爬楼梯。到2021年，报告有这种困难的人的比例持平：2019年12月，9.6%的成年人是残疾人，而两年后的比例为9.5%。

2012年至2022年SSA残疾申请和CPS调查数据的图表
其他来源的残疾数据确实暗示了--但只是暗示--长期COVID的后果。当美国劳工统计局进行月度就业调查时，它向美国人询问了一些关于他们身体和认知健康的基本问题，包括他们是否有注意力不集中、做决定、走路或跑腿的困难。根据这一衡量标准，报告此类问题的人数在2021年中期开始逐步上升。(残疾率在大流行开始时短暂出现下降，当时亲自面试被搁置）。但这一增长，从工作年龄人口的约7.5%到8%，与推断出的长期患有COVID的美国人的数量相比，只是一个小插曲，而且这个新的队列中大多数人仍然能够工作。梅斯塔斯怀疑这些特殊的残疾数字代表了真正的上升的第一个迹象。"她说："当你看着它们每季度不断上升时，它开始看起来也许有什么事情发生了。

上述调查措施可能会受到该大流行病在已经残疾的人中造成的不成比例的死亡的轻微影响。它们也只能说明故事的一个部分。充其量，他们会捕捉到某种长期的COVID--那种导致脑雾、疲劳和虚弱，以及其他严重的记忆力、注意力和行动力的损害。这里的一个首要问题是，长COVID也与许多其他疾病有关，如内部震颤、突然心悸和严重的过敏反应。这些问题都不可能出现在NHIS或BLS的数据中，更不用说让某人有资格获得社会安全局的长期财政支持。

如果 "大规模致残事件 "表现为数以千万计的神经疼痛或腹泻，例如，甚至只是持续的嗅觉丧失，那么你可能永远不会看到报告有功能障碍的美国人的数量大增。不过，在这种情况下，更多的美国人可能最终会去找他们的医生进行评估、测试和治疗。总的来说，越来越多的症状应该导致国家的医疗保健系统的负担越来越重。

现有的数据表明，至少在目前，情况恰恰相反。凯撒家庭基金会去年秋天发布的一份报告发现，到2021年上半年，门诊和住院病人的医疗支出实际上比预计的要低--即使考虑到数百万急性病的COVID患者。"非营利组织写道："我们没有看到因延迟或放弃护理而被压抑的需求。(尽管在大流行的头两年里，拥有健康保险的美国人的比例增加了，但这种适度的支出还是被记录下来了）。2月，咨询公司麦肯锡调查了全国101家医院的领导人，他们说门诊和手术仍然低于大流行前的水平。大流行对医疗工作者的影响一定是导致数量下降的原因，但它不能说明所有的问题。根据麦肯锡的数据，大多数病人仍然可以在两三周内抢到专家预约。


许多长途旅行者可能只是放弃了获得医疗服务，因为他们可以理解地认为不存在治疗方法，或者医生不相信他们有病。英国国家统计局一直在进行世界上最大的长COVID调查之一，以努力衡量这种幕后痛苦的全部程度。该研究显示，截至5月初，该国3%的居民被认定为患有长期COVID，广义的定义是在首次患病超过4周后 "仍有[任何]症状"（英国80%的人口估计至少感染过一次冠状病毒）。这个群体中约有三分之二的人--相当于100多万人--说这种情况影响了他们进行日常活动的能力。调查中提到最多的慢性症状是虚弱、呼吸短促、注意力难以集中、肌肉酸痛和头痛。

阅读：身为黑人和残疾人是一场持续的斗争

在关注持续的症状时，英国的调查可能忽略了COVID的其他更隐蔽的后果。上个月发表的CDC分析报告研究了数十万成年COVID患者的医疗记录，并得出结论，每五个人中至少有一个人可能会经历病后并发症。其中一些是我们熟悉的类型（呼吸困难、肌肉疼痛）；其他则是定时炸弹，包括血凝块、肾衰竭和心脏病发作。这项研究的方法受到了严厉的批评--长期服用COVID的人 "应该得到更好的待遇，好得多"，匹兹堡大学的医学教授Walid Gellad告诉我，而且五分之一的统计数字可能太高。但是，如果CDC的结果在实质上是正确的--如果各种死亡危险在COVID之后确实大幅增加--那么这些影响在人群中也应该是可以检测到的。耶鲁大学的经济学家和健康政策专家Jason Abaluck告诉我，个别研究结果和整体疾病负担之间的比较为极端的发现提供了现实的检验。"他们允许你对事情进行限制。"


这让我们在哪里长COVID？大多数美国人已经遇到了这种病毒，许多人还不止一次。疾病预防控制中心建议，这些人平均会经历约50%的血栓、肾衰竭和心脏病发作以及糖尿病和哮喘的各自风险的增加。全面的国家疾病估计将需要多年时间来编制，但自2019年以来，心脏病、中风和肾脏疾病的临时死亡率并没有真正发生变化，而且国家健康保险调查显示，患有高血压或哮喘的美国人数量没有增加。

简而言之，我们现在可以这样说。残疾率可能会上升，但只是一点点；医疗保健系统似乎正在应对；COVID后并发症的死亡人数没有增加；劳动力正在保持。换句话说，在这场大流行病的其他社会动荡中，Long COVID还没有脱颖而出。

莉莎-费舍尔患有长COVID，她在数据中显示出来。这位来自休斯顿的38岁前空姐和瑜伽教练在2020年6月患上了COVID。她的感染导致了几个月的住院治疗、手术和康复。她现在需要一个医疗专家团队，而且由于神经系统症状、疲劳和过敏反应，她的日常活动仍然受到严重限制。费舍尔在症状开始后就请了病假，而且再也没有回来。2020年12月，她向社会安全局申请了残疾津贴，大约6个月后获得了津贴。


"政府的数字并不准确，而且可能永远不会准确，"费希尔告诉我。她知道有一些长寿者在更好的诊断下申请了残疾项目，例如，因为他们认为引用长寿的COVID不会给予他们机会。她说，当国家指标不能反映长COVID群体的日常现实时，倡导研究、治疗和支持服务变得更加困难。

阅读。我们甚至没有尝试的长COVID的有希望的治疗方法

弗兰克-齐格勒也患有长COVID，但他没有辞去工作，也没有提出任何福利要求。来自田纳西州纳什维尔的58岁律师Ziegler在2021年1月患上了轻微的COVID病例。他所经历的鼻塞是如此不起眼，以至于他一开始以为自己得了简单的鼻窦感染。但在康复过程中，齐格勒的胃口发生了一些变化--似乎是好的。他以前喜欢的食物变得很奇怪，没有胃口；他的体重明显下降。然后他开始注意到手的颤抖、呼吸困难和认知问题。一系列的医学检查结果基本正常，但齐格勒仍然感觉不如感染病毒前那样好。他的生活发生了变化，但这种变化可能不会反映在任何政府图表上。"他告诉我："长期感染COVID的病人的方钉子永远无法塞进传统测试的圆孔里。


定义长期COVID的各种症状和经历的混合表明，没有任何单一的措施，或一组措施，可以说明长期患者的总体痛苦。在我们掌握的数据中，一个 "大规模致残事件 "并没有上演。这可能会在未来几个月和几年内发生变化，否则它可能表明我们正处于另一种时刻，一种让数千万美国人感觉比以前更糟的时刻，他们没有病到无法坚持工作或需要医疗照顾，但也没有完全恢复到基线。把它称为 "大规模恶化事件"。

"有相当数量的人不能简单地继续前进，"齐格勒告诉我。"他们中的许多人不知道为什么他们会有这样的感觉，而且他们一直无法得到任何缓解。" 这种形式的流行病--一种逐步降低数百万人生活质量的流行病--很可能正在展开，甚至包括费舍尔在内的更小的患者群体看到他们的生活被慢性疾病彻底改变。我们不知道慢性病危机会变得多么严重，但对许多人来说，已经没有回头路了。

本杰明-马泽尔是一名专门从事实验室医学的医生。