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March 11 marks 3 years since WHO declared COVID-19 to be a pandemic. While the world is determined to move on from the acute phase, at least 65 million people are estimated to struggle with long COVID, a debilitating post-infection multisystem condition with common symptoms of fatigue, shortness of breath, and cognitive dysfunction, impairing their ability to perform daily activities for several months or years. Although the majority of patients infected with SARS-CoV-2 recover within a few weeks, long COVID is estimated to occur in 10–20% of cases and affects people of all ages, including children, with most cases occurring in patients with mild acute illness. The consequence is widespread global harm to people's health, wellbeing, and livelihoods—an estimated one in ten people who develop long COVID stop working, resulting in extensive economic losses. In 2021, we called for a coordinated research and health-care agenda to tackle this new medical challenge. However, progress has been excruciatingly slow due to lack of attention and resources.

g, and livelihoods—an estimated one in ten people who develop long COVID stop working, resulting in extensive economic losses. In 2021, we called for a coordinated research and health-care agenda to tackle this new medical challenge. However, progress has been excruciatingly slow due to lack of attention and resources. Some progress has been made in our understanding of its multifaceted and heterogeneous nature. In a Comment in The Lancet Infectious Diseases, Iwasaki and Putrino consider the possible causes, including viral persistence, autoimmunity triggered by the infection, reactivation of latent viruses, and inflammation-triggered chronic changes leading to organ damage, which might explain the different phenotypes exhibited by long COVID patients. Several candidate treatments are being tested, based on differing symptoms and biological mechanisms. Because of long COVID's diverse symptomatology, reliance on self-reported symptoms, and a lack of diagnostic tests and consensus definition, many patients struggle to obtain a definitive diagnosis. As a result, long COVID is often easily dismissed as a psychosomatic condition. Given what we now know about the effects of long COVID and its biological basis, it must be taken seriously.

eported symptoms, and a lack of diagnostic tests and consensus definition, many patients struggle to obtain a definitive diagnosis. As a result, long COVID is often easily dismissed as a psychosomatic condition. Given what we now know about the effects of long COVID and its biological basis, it must be taken seriously. On a global scale, long COVID has not received the attention it deserves and there is a general lack of public awareness. In many places, data on long COVID are absent, especially in low-income and middle-income countries. Where studies have been done—such as in India, China, and South Africa—long COVID has been found. A global coordinated multidisciplinary research agenda, bringing together governments, non-governmental organisations, and civil society, is essential to improve our understanding of the cause and pathogenesis, clinical diagnosis, treatments, risk factors, and prevention of long COVID. It was only in December, 2022, that the USA and the European Commission had a conference to foster international cooperation. In August, 2022 the USA set up the National Research Action Plan on Long COVID, which led the US National Institutes of Health to allocate $1·15 billion to the Researching COVID to Enhance Recovery (RECOVER) project. The EU has yet to define a research agenda for long COVID and Long COVID Europe (a network of patient associations) is calling for €500 million in EU emergency research funds.

COVID, which led the US National Institutes of Health to allocate $1·15 billion to the Researching COVID to Enhance Recovery (RECOVER) project. The EU has yet to define a research agenda for long COVID and Long COVID Europe (a network of patient associations) is calling for €500 million in EU emergency research funds. Without specific treatments for long COVID, attention needs to fall on prevention—keeping COVID-19 cases low and ensuring vaccination—and patient-centred multidisciplinary care. Patients, many with complex multimorbidities, need multisectoral physical, cognitive, social, and occupational support. The outlook for such care appears only to have worsened. Primary care has suffered in many countries, waiting lists have lengthened, and health systems are struggling. Education and awareness on the clinical management of long COVID in primary care remains insufficient and inequities in care continue. Reliable and authoritative platforms to support and guide patients are still absent in many places. Delays in care and support prolong and exacerbate the symptoms of long COVID. There is little sense that social supports—particularly around employment—have been introduced to meet the needs of patients.

n care continue. Reliable and authoritative platforms to support and guide patients are still absent in many places. Delays in care and support prolong and exacerbate the symptoms of long COVID. There is little sense that social supports—particularly around employment—have been introduced to meet the needs of patients. The acute months of the COVID-19 pandemic motivated an unprecedented response from governments, international organisations, pharmaceutical companies, and civil society. Long COVID has not received anywhere near the same level of attention or resources: the result has been widespread harm to health, societies, and economies. 3 years in, more is needed to recognise, treat, and support patients with long COVID.

ts, international organisations, pharmaceutical companies, and civil society. Long COVID has not received anywhere near the same level of attention or resources: the result has been widespread harm to health, societies, and economies. 3 years in, more is needed to recognise, treat, and support patients with long COVID. For more on the prevalence of long COVID see https://www.nature.com/articles/s41579-022-00846-2#ref-CR5 For more on labour losses see https://ifs.org.uk/publications/long-covid-and-labour-market For more on the pathogenesis of long COVID see Comment Lancet Infect Dis 2023; published online Feb 14. https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(23)00053-1/fulltext For more on candidate treatments see https://www.nature.com/articles/s41579-022-00846-2/tables/1 For more on the pandemic preparedness treaty see https://apps.who.int/gb/inb/pdf_files/inb4/A_INB4_3-en.pdf For more on the US-EC conference see https://health.ec.europa.eu/events/online-eu-us-conference-long-covid-2022-12-13_en For more the US national action plan see https://www.covid.gov/assets/files/National-Research-Action-Plan-on-Long-COVID-08012022.pdf For more on the RECOVER project see https://recovercovid.org/ For more on inequities in care see https://www.independent.co.uk/news/health/long-covid-postcode-lottery-care-b2095428.html For more on the prevalence of long COVID see https://www.nature.com/articles/s41579-022-00846-2#ref-CR5 For more on labour losses see https://ifs.org.uk/publications/long-covid-and-labour-market

For more on the prevalence of long COVID see https://www.nature.com/articles/s41579-022-00846-2#ref-CR5 For more on labour losses see https://ifs.org.uk/publications/long-covid-and-labour-market For more on the pathogenesis of long COVID see Comment Lancet Infect Dis 2023; published online Feb 14. https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(23)00053-1/fulltext For more on candidate treatments see https://www.nature.com/articles/s41579-022-00846-2/tables/1 For more on the pandemic preparedness treaty see https://apps.who.int/gb/inb/pdf_files/inb4/A_INB4_3-en.pdf For more on the US-EC conference see https://health.ec.europa.eu/events/online-eu-us-conference-long-covid-2022-12-13_en For more the US national action plan see https://www.covid.gov/assets/files/National-Research-Action-Plan-on-Long-COVID-08012022.pdf For more on the RECOVER project see https://recovercovid.org/ For more on inequities in care see https://www.independent.co.uk/news/health/long-covid-postcode-lottery-care-b2095428.html For more on the prevalence of long COVID see https://www.nature.com/articles/s41579-022-00846-2#ref-CR5 For more on labour losses see https://ifs.org.uk/publications/long-covid-and-labour-market For more on the pathogenesis of long COVID see Comment Lancet Infect Dis 2023; published online Feb 14. https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(23)00053-1/fulltext For more on candidate treatments see https://www.nature.com/articles/s41579-022-00846-2/tables/1 For more on the pandemic preparedness treaty see https://apps.who.int/gb/inb/pdf_files/inb4/A_INB4_3-en.pdf

For more on the pathogenesis of long COVID see Comment Lancet Infect Dis 2023; published online Feb 14. https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(23)00053-1/fulltext For more on candidate treatments see https://www.nature.com/articles/s41579-022-00846-2/tables/1 For more on the pandemic preparedness treaty see https://apps.who.int/gb/inb/pdf_files/inb4/A_INB4_3-en.pdf For more on the US-EC conference see https://health.ec.europa.eu/events/online-eu-us-conference-long-covid-2022-12-13_en For more the US national action plan see https://www.covid.gov/assets/files/National-Research-Action-Plan-on-Long-COVID-08012022.pdf For more on the RECOVER project see https://recovercovid.org/ For more on inequities in care see https://www.independent.co.uk/news/health/long-covid-postcode-lottery-care-b2095428.html © 2023 SOPA Images/Getty Images2023