[House Hearing, 117 Congress]
[From the U.S. Government Publishing Office]


                THE LONG HAUL: FORGING A PATH THROUGH 
                 THE LINGERING EFFECTS OF COVID-19

=======================================================================

                            VIRTUAL HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             APRIL 28, 2021

                               __________

                           Serial No. 117-25
                           
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]                           


     Published for the use of the Committee on Energy and Commerce
                   govinfo.gov/committee/house-energy
                        energycommerce.house.gov
                        
                                __________

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
47-313 PDF                 WASHINGTON : 2022                     
          
-----------------------------------------------------------------------------------                          
                        
                        
                        
                    COMMITTEE ON ENERGY AND COMMERCE

                     FRANK PALLONE, Jr., New Jersey
                                 Chairman
BOBBY L. RUSH, Illinois              CATHY McMORRIS RODGERS, Washington
ANNA G. ESHOO, California              Ranking Member
DIANA DeGETTE, Colorado              FRED UPTON, Michigan
MIKE DOYLE, Pennsylvania             MICHAEL C. BURGESS, Texas
JAN SCHAKOWSKY, Illinois             STEVE SCALISE, Louisiana
G. K. BUTTERFIELD, North Carolina    ROBERT E. LATTA, Ohio
DORIS O. MATSUI, California          BRETT GUTHRIE, Kentucky
KATHY CASTOR, Florida                DAVID B. McKINLEY, West Virginia
JOHN P. SARBANES, Maryland           ADAM KINZINGER, Illinois
JERRY McNERNEY, California           H. MORGAN GRIFFITH, Virginia
PETER WELCH, Vermont                 GUS M. BILIRAKIS, Florida
PAUL TONKO, New York                 BILL JOHNSON, Ohio
YVETTE D. CLARKE, New York           BILLY LONG, Missouri
KURT SCHRADER, Oregon                LARRY BUCSHON, Indiana
TONY CARDENAS, California            MARKWAYNE MULLIN, Oklahoma
RAUL RUIZ, California                RICHARD HUDSON, North Carolina
SCOTT H. PETERS, California          TIM WALBERG, Michigan
DEBBIE DINGELL, Michigan             EARL L. ``BUDDY'' CARTER, Georgia
MARC A. VEASEY, Texas                JEFF DUNCAN, South Carolina
ANN M. KUSTER, New Hampshire         GARY J. PALMER, Alabama
ROBIN L. KELLY, Illinois, Vice       NEAL P. DUNN, Florida
    Chair                            JOHN R. CURTIS, Utah
NANETTE DIAZ BARRAGAN, California    DEBBBIE LESKO, Arizona
A. DONALD McEACHIN, Virginia         GREG PENCE, Indiana
LISA BLUNT ROCHESTER, Delaware       DAN CRENSHAW, Texas
DARREN SOTO, Florida                 JOHN JOYCE, Pennsylvania
TOM O'HALLERAN, Arizona              KELLY ARMSTRONG, North Dakota
KATHLEEN M. RICE, New York
ANGIE CRAIG, Minnesota
KIM SCHRIER, Washington
LORI TRAHAN, Massachusetts
LIZZIE FLETCHER, Texas
                                 ------                                

                           Professional Staff

                   JEFFREY C. CARROLL, Staff Director
                TIFFANY GUARASCIO, Deputy Staff Director
                  NATE HODSON, Minority Staff Director
                         Subcommittee on Health

                       ANNA G. ESHOO, California
                                Chairwoman
G. K. BUTTERFIELD, North Carolina    BRETT GUTHRIE, Kentucky
DORIS O. MATSUI, California            Ranking Member
KATHY CASTOR, Florida                FRED UPTON, Michigan
JOHN P. SARBANES, Maryland, Vice     MICHAEL C. BURGESS, Texas
    Chair                            H. MORGAN GRIFFITH, Virginia
PETER WELCH, Vermont                 GUS M. BILIRAKIS, Florida
KURT SCHRADER, Oregon                BILLY LONG, Missouri
TONY CARDENAS, California            LARRY BUCSHON, Indiana
RAUL RUIZ, California                MARKWAYNE MULLIN, Oklahoma
DEBBIE DINGELL, Michigan             RICHARD HUDSON, North Carolina
ANN M. KUSTER, New Hampshire         EARL L. ``BUDDY'' CARTER, Georgia
ROBIN L. KELLY, Illinois             NEAL P. DUNN, Florida
NANETTE DIAZ BARRAGAN, California    JOHN R. CURTIS, Utah
LISA BLUNT ROCHESTER, Delaware       DAN CRENSHAW, Texas
ANGIE CRAIG, Minnesota               JOHN JOYCE, Pennsylvania
KIM SCHRIER, Washington              CATHY McMORRIS RODGERS, Washington 
LORI TRAHAN, Massachusetts               (ex officio)
LIZZIE FLETCHER, Texas
FRANK PALLONE, Jr., New Jersey (ex 
    officio)
                             
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Anna G. Eshoo, a Representative in Congress from the State 
  of California, opening statement...............................     2
    Prepared statement...........................................     3
Hon. Brett Guthrie, a Representative in Congress from the 
  Commonwealth of Kentucky, opening statement....................     4
    Prepared statement...........................................     5
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     6
    Prepared statement...........................................     7
Hon. Cathy McMorris Rodgers, a Representative in Congress from 
  the State of Washington, opening statement.....................     8
    Prepared statement...........................................     9

                               Witnesses

Francis S. Collins, M.D., Director, National Institutes of 
  Health, Department of Health and Human Services................    10
    Prepared statement...........................................    13
    Answers to submitted questions...............................   231
John T. Brooks, M.D., Chief Medical Officer, CDC COVID-19 
  Response, Centers for Disease Control and Prevention, 
  Department of Health and Human Services........................    18
    Prepared statement...........................................    20
    Answers to submitted questions...............................   236
Natalie Hakala, Collegiate Middle-Distance Runner and Long COVID 
  Patient, Eugene, OR............................................    87
    Prepared statement...........................................    89
Chimere L. Smith, Long COVID Patient Advocate for Urban 
  Communities, Baltimore, MD.....................................    94
    Prepared statement...........................................    96
    Submitted questions for the record \1\                          238
Lisa McCorkell, Team Lead and Researcher, Patient-Led Research 
  Collaborative, Oakland, CA.....................................   101
    Prepared statement...........................................   103
Jennifer D. Possick, M.D., Associate Professor, Pulmonary, 
  Critical Care and Sleep Medicine, and Medical Director, 
  Winchester Center for Lung Disease, Yale-New Haven Hospital....   120
    Prepared statement...........................................   122
    Answers to submitted questions...............................   241
Steven Deeks, M.D., Professor of Medicine, University of 
  California, San Francisco......................................   127
    Prepared statement...........................................   129

                           Submitted Material

Letter of April 21, 2021, from Mr. Burgess, et al., to Hon. Nancy 
  Pelosi, Speaker, House of Representatives, submitted by Ms. 
  Eshoo..........................................................   154
Letter of April 27, 2021, from Gary L. LeRoy, Board Chair, 
  American Academy of Family Physicians, to Ms. Eshoo and Mr. 
  Guthrie, submitted by Ms. Eshoo................................   158
Statement of the American Academy of Physical Medicine and 
  Rehabilitation, April 28, 2021, submitted by Ms. Eshoo.........   162

----------

\1\ Ms. Smith did not answer submitted questions for the record by the 
time of publication.
Letter of April 27, 2021, from Michael O. Leavitt and Nancy-Ann 
  DeParle, Co-conveners, COVID Patient Recovery Alliance, to Mr. 
  Pallone, et al., submitted by Ms. Eshoo........................   172
Statement of the Council for Quality Respiratory Care, submitted 
  by Ms. Eshoo...................................................   174
Statement of Rajarshi Banerjee, April 28, 2021, submitted by Ms. 
  Eshoo..........................................................   180
Statement, ``A Call to Action: Immediate Deployment Of Select 
  Repurposed Drugs For COVID-19 Outpatient Treatment,'' by Vikas 
  P. Sukhatme and Vidula V. Sukatme, submitted by Ms. Eshoo......   185
Statement of the American Physical Therapy Association, April 28, 
  2021, submitted by Ms. Eshoo...................................   191
Letter of April 27, 2021, from Thomas F. Bumol, Executive Vice 
  President and Director, Allen Institute for Immunology, to Mrs. 
  Rodgers, submitted by Ms. Eshoo................................   195
Statement of Survivor Corps by Natalie Lambert, et al., April 28, 
  2021, submitted by Ms. Eshoo...................................   197
Statement of Survivor Corps by Diana Berrent, Founder, et al., 
  April 28, 2021, submitted by Ms. Eshoo.........................   209
Report of April 2021, ``Survivor Corps Overview,'' submitted by 
  Ms. Eshoo......................................................   213

 
THE LONG HAUL: FORGING A PATH THROUGH THE LINGERING EFFECTS OF COVID-19

                              ----------                              


                       WEDNESDAY, APRIL 28, 2021

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 11:26 a.m., via 
Cisco Webex online video conferencing, Hon. Anna G. Eshoo 
(chairwoman of the subcommittee) presiding.
    Members present: Representatives Eshoo, Butterfield, 
Matsui, Castor, Sarbanes, Welch, Schrader, Cardenas, Ruiz, 
Dingell, Kuster, Kelly, Barragan, Blunt Rochester, Craig, 
Schrier, Trahan, Fletcher, Pallone (ex officio), Guthrie 
(subcommittee ranking member), Upton, Burgess, Griffith, 
Bilirakis, Bucshon, Hudson, Carter, Dunn, Curtis, Joyce, and 
Rodgers (ex officio).
    Also present: Representatives Schakowsky, Doyle, Clarke, 
and Rice.
    Staff present: Joe Banez, Professional Staff Member; 
Jeffrey C. Carroll, Staff Director; Waverly Gordon, General 
Counsel; Tiffany Guarascio, Deputy Staff Director; Perry 
Hamilton, Clerk; MacKenzie Kuhl, Digital Assistant; Aisling 
McDonough, Policy Coordinator; Meghan Mullon, Policy Analyst; 
Kaitlyn Peel, Digital Director; Tim Robinson, Chief Counsel; 
Chloe Rodriguez, Clerk; Kylea Rogers, Staff Assistant; 
Kimberlee Trzeciak, Chief Health Advisor; C.J. Young, Deputy 
Communications Director; Sarah Burke, Minority Deputy Staff 
Director; Theresa Gambo, Minority Financial and Office 
Administrator; Grace Graham, Minority Chief Counsel, Health; 
Caleb Graff, Minority Deputy Chief Counsel, Health; Nate 
Hodson, Minority Staff Director; Peter Kielty, Minority General 
Counsel; Emily King, Minority Member Services Director; Clare 
Paoletta, Minority Policy Analyst, Health; Kristin Seum, 
Minority Counsel, Health; Kristen Shatynski, Minority 
Professional Staff Member, Health; Olivia Shields, Minority 
Communications Director; Michael Taggart, Minority Policy 
Director; and Everett Winnick, Minority Director of Information 
Technology.
    Ms. Eshoo. The Subcommittee on Health will now come to 
order.
    Thank you, Members, for your patience, and the witnesses. 
We had technical difficulties because of, evidently, a 
potential tornado somewhere in our country. So thank you to the 
team for getting us connected. And I want to welcome everyone 
to our very important hearing this morning.
    Due to COVID-19, today's hearing obviously is being held 
remotely. All Members and witnesses are participating via video 
conferencing.
    As part of our hearing, microphones will be set on mute to 
eliminate background noise. Members and witnesses, you will 
need to unmute your microphone each time you wish to speak. 
Documents for the record--and this is for all the Members and 
their offices--should be sent to Meghan Mullon at the email 
address that we provided to your staff. And all documents will 
be entered into the record at the conclusion of the hearing.
    The Chair now recognizes herself for 5 minutes for an 
opening statement.

 OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    This morning's hearing is to examine the trends and 
research into long COVID, a chronic syndrome occurring in 
patients infected by COVID-19. This is the first congressional 
hearing focused on this issue. The few large-formal studies 
conducted on long COVID hint at an alarming scale of people 
with the illness.
    Last week, CDC published a study finding that among adults 
with COVID who did not require a hospital stay, two out of 
three had at least one outpatient visit 1 to 6 months after 
diagnosis. People with long COVID report experiencing different 
combinations of symptoms, including fatigue, brain fog, 
headache, loss of smell or taste, shortness of breath, and 
chronic pain. Since this disease affects multiple body systems, 
the symptoms can be much more extensive.
    This research suggests that in the United States, where 
there have been more than 32 million confirmed COVID-19 cases, 
there could be millions of long-haulers with chronic symptoms. 
Our health system is facing an avalanche of long COVID 
patients, and I hear every day from constituents suffering from 
the long-term effects of the virus.
    Our expert witnesses today will provide the latest 
information on the lingering effects of COVID-19 and the 
limited options for treatment. We will also hear firsthand from 
long-haul patients. They will provide a perspective that we 
wouldn't get from statistics and medical studies. So we are 
very grateful to them for their willingness to share their 
experience with us. And certainly they will underscore the 
human cost of long COVID.
    Long-COVID patients don't fit the common narrative of 
COVID-19--a patient being an elderly person, for example, with 
preexisting conditions. And they cover, really, right across 
our communities. They are elite athletes, they are midcareer 
professionals. And because of this, many long-haulers struggle 
to be taken seriously by our medical system, especially--and 
here we go again--especially Black women and women of color.
    My fear is that, as acute COVID uncovered our Nation's 
failures at emergency response and equitable healthcare, long 
COVID will uncover our failures at fairly treating chronic 
disease and disability.
    For sure, Federal leadership is going to be needed to 
coordinate and address the swell of the long-haul COVID 
patients. We may need a nationwide network of long-COVID 
clinics with multidisciplinary clinical teams. Long-COVID 
patients are also finding gaps that need to be filled in our 
safety net, such as disability insurance, workplace 
accommodations, and comprehensive insurance coverage.
    There is hope on the horizon, though, having stated all the 
things that I have. In the next few days, the NIH will announce 
millions of dollars in grant funding for long-COVID 
researchers. Also, with every American adult now eligible for 
the COVID-19 vaccine, we will prevent future long-COVID cases, 
and in some cases perhaps reduce long-COVID patients' symptoms. 
These patients are showing us how to rebuild a better health 
system for the millions of Americans who are disabled or have 
chronic conditions.
    [The prepared statement of Ms. Eshoo follows:]

                Prepared Statement of Hon. Anna G. Eshoo

    This morning's hearing is to examine the trends and 
research into long COVID, the chronic syndrome occurring in 
patients infected by COVID-19. This is the first congressional 
hearing focused on long COVID.
    The few large, formal studies conducted on long COVID hint 
at an alarming scale of people with the illness. Last week CDC 
published a study finding that among adults with COVID who did 
not require a hospital stay, 2 out of 3 had at least one 
outpatient visit 1 to 6 months after diagnosis.
    People with long COVID report experiencing different 
combinations of symptoms, including fatigue, brain fog, 
headache, loss of smell or taste, shortness of breath, and 
chronic pain. Since this disease affects multiple body systems, 
the symptoms can be much more extensive.
    This research suggests that in the U.S. where there've been 
more than 32 million confirmed COVID-19 cases, there could be 
millions of long-haulers with chronic symptoms. And our health 
system is facing an avalanche of long-COVID patients. I hear 
every day from constituents suffering from the long-term 
effects of the virus.
    Our expert witnesses today will provide the latest 
information on the lingering effects of COVID-19 and the 
limited options for treatment.
    We'll also hear firsthand from long-haul patients. These 
patients provide a perspective that we wouldn't get from 
statistics and medical studies. They'll share the human cost of 
long COVID.
    Long-COVID patients don't fit the common narrative of a 
COVID-19 patient being an elderly person with preexisting 
conditions. They are elite athletes and mid-career 
professionals. Because of this, many long haulers have 
struggled to be taken seriously by our medical system, 
especially Black women and women of color.
    My fear is that as acute COVID uncovered our Nation's 
failures at emergency response and equitable healthcare, long 
COVID will uncover our failures at fairly treating chronic 
disease and disability.
    We'll need Federal leadership to coordinate and address the 
swell of long-COVID patients. We may need a nationwide network 
of long-COVID clinics with multidisciplinary clinical teams. 
Long-COVID patients are also finding gaps that need to be 
filled in our safety net, such as disability insurance, 
workplace accommodations, and comprehensive insurance coverage.
    There is hope on the horizon. In the next few days the NIH 
will announce millions of dollars in grant funding for long-
COVID researchers. Also, with every American adult now eligible 
for the COVID-19 vaccine, we will prevent future long-COVID 
cases and, in some cases, perhaps reduce long-COVID patients' 
symptoms. These patients are showing us how to rebuild a better 
health system for the millions of Americans who are disabled or 
have chronic conditions.

    Ms. Eshoo. The Chair now recognizes my friend and ranking 
member of our subcommittee, Mr. Guthrie, for his 5 minutes for 
an opening statement.
    It is great to see you.

 OPENING STATEMENT OF HON. BRETT GUTHRIE, A REPRESENTATIVE IN 
           CONGRESS FROM THE COMMONWEALTH OF KENTUCKY

    Mr. Guthrie. Great to see you. Thanks, Chair Eshoo, for 
holding this hearing. And I want to welcome everybody, 
especially our witnesses that are with us today.
    Unfortunately, over 31 million Americans have tested 
positive for COVID-19, and some of these Americans experience 
symptoms weeks and months after being infected with COVID-19. 
And today we will examine the long-term effects of this life-
threatening virus.
    These long-term effects are often referred to as post-acute 
COVID-19 or long COVID. We still have many questions about how 
individuals recover from this terrible virus.
    Last May, I joined the--Chair Eshoo, Representatives 
Burgess, DeGette, and Trone, introducing the Ensuring 
Understanding of COVID-19 to Protect Public Health Act. And 
this bill requires NIH, in consultation with CDC, to conduct a 
longitudinal study on the health impacts of COVID-19.
    At the time, we were just starting to learn about COVID-19 
long-haulers and some of the side effects this virus has on a 
percentage of Americans post-COVID-19 infection. At the end of 
last year, Congress came together to include $1.15 billion in 
the December funding package for just this reason, to learn 
more about this issue.
    While we know more today than last year, we still have many 
unanswered questions. In America, we are fortunate to have 
access to the best medical experts in the world, who are 
diligently working to quickly find answers to these questions.
    I want to thank Dr. Collins and Dr. Brooks for being here 
today to explain what is currently understood about this 
condition and provide an update on what NIH and CDC are doing 
to further study long-term COVID.
    I also want to thank the witnesses on the second panel. I 
look forward to hearing and learning from you more about how 
you are helping patients with long-term COVID, and for the 
patient witnesses, how COVID-19 is still impacting you.
    I was pleased to learn that in December, the National 
Institute of Allergy and Infectious Diseases, in collaboration 
with other institutes and centers of the NIH, hosted a workshop 
on postacute sequelae of COVID-19 to examine the knowledge gaps 
that we currently have regarding the long-term effects that 
some individuals are experiencing.
    Additionally, I appreciate CDC efforts to educate the 
public on the symptoms that might present themselves as long 
COVID.
    I want to help get people back to work and back to their 
daily lives before COVID-19. However, people have reported that 
long-COVID symptoms are preventing them from returning to their 
jobs and making it more difficult to do many activities they 
once easily could.
    We must help patients receive proper treatments and learn 
ways to resolve these symptoms. I often hear of long-COVID 
cases, and each one seems to be different with varying symptoms 
and severity. Studying these patients will be valuable and 
instrumental in the many Americans' day-to-day life post COVID.
    Lastly, I want to take this time to encourage all Americans 
to get vaccinated. There is no better protection for this 
terrible virus than one of the FDA-approved vaccines that are 
currently available. Long COVID can be avoided with 
vaccination. Operation Warp Speed and American innovation has 
led to three safe and effective vaccines being approved. Now it 
is time to put your guard down--or rather get--now is not time 
to put your guard down but, rather, get vaccinated to protect 
yourself and those around you.
    Thank you, Chair. And I yield back.
    [The prepared statement of Mr. Guthrie follows:]

                Prepared Statement of Hon. Brett Guthrie

    Chair Eshoo, thank you for holding this important hearing 
today.
    Unfortunately, over 31 million Americans have tested 
positive for COVID-19, and some of these Americans experience 
symptoms weeks and months after being infected with COVID-19. 
Today we will examine the long-terms effects of this life-
threatening virus. These long-term effects are often referred 
to as post-acute COVID-19, or long COVID. We still have many 
questions about how individuals recover from this terrible 
virus.
    Last May, I joined Chair Eshoo, Rep. Burgess, Rep. DeGette, 
and Rep. Trone in introducing the Ensuring Understanding of 
COVID-19 to Protect Public Health Act. This bill requires the 
National Institutes of Health (NIH), in consultation with the 
Centers for Disease Control and Prevention (CDC), to conduct a 
longitudinal study on the health impacts of COVID-19. At the 
time, we were just starting to learn about COVID ``long-
haulers'' and some of the side effects this virus has on a 
percentage of Americans post COVID-19 infection.
    In December, Congress came together to include $1.15 
billion in the December funding package for just this reason--
to learn more about this issue.
    While we know more today than last year, we still have many 
unanswered questions. In America, we are fortunate to have 
access to the best medical experts in the world who are 
diligently working to quickly find answers to these questions.
    I want to thank Dr. Collins and Dr. Brooks for being here 
today to explain what is currently understood about this 
condition and provide an update on what NIH and CDC are doing 
to further study long COVID. I also want to thank the witnesses 
on the second panel. I look forward to learning more about how 
COVID-19 is still impacting you.
    I was pleased to learn that in December the National 
Institute of Allergy and Infectious Diseases (NIAID), in 
collaboration with other institutes and centers of the National 
Institutes of Health, hosted a Workshop on Post-acute Sequelae 
of COVID-19 to examine the ``knowledge gaps'' that we currently 
have regarding the long-term effects that some individuals are 
experiencing.
    Additionally, I appreciate CDC's efforts to educate the 
public on the symptoms that may present themselves as long 
COVID. I want to help get people back to work. However, people 
have reported that long-COVID symptoms are preventing them from 
returning to their jobs. We must help patients receive proper 
treatments and learn ways to resolve these symptoms. I often 
hear of long-COVID cases and each one seems to be different 
with varying symptoms and severity. Studying these patients 
will be valuable and instrumental in many Americans' day-to-day 
life post COVID.
    Lastly, I want to take this time to encourage all Americans 
to get vaccinated. There is no better protection from this 
terrible virus than one of the FDA approved vaccines that are 
currently available. Long COVID can be avoided with 
vaccination. Operation Warp Speed and American innovation has 
led to three and safe effective vaccines being approved. Now is 
not the time to put your guard down but rather get vaccinated 
to protect yourself and those around you.
    Thank you Chair, I yield back.

    Ms. Eshoo. The gentleman yields back. And the Chair thanks 
him for essentially that call to arms.
    The Chair now recognizes Mr. Pallone, the Chairman of the 
full committee, for his 5 minutes for an opening statement.

OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Chairwoman Eshoo.
    We have been battling COVID-19 for more than a year now, 
and while much has changed in terms of our knowledge and 
ability to combat this disease, it continues to present these 
new health challenges. And over 30 million Americans have 
tested positive for COVID-19 over the last year, nearly 600,000 
have died, and the loss has been devastating. And we are always 
mindful of the toll this pandemic takes on our families and 
friends and communities.
    But over the last year, this subcommittee has played a key 
role in responding to the ongoing public health crisis. Today, 
we continue that crucial work as we discuss a consequence of 
COVID-19 that is perplexing the scientific community.
    A growing number of individuals are experiencing the 
lingering effects of COVID-19 weeks and months after their 
initial infection. These lingering symptoms are being described 
as long COVID, and it seems to be impacting a lot of people who 
are otherwise healthy.
    A full picture of long COVID is still being drawn. 
Generally, someone is considered to have long COVID if they 
experience symptoms lasting longer than 4 weeks after their 
initial infection. Symptoms can include persistent fatigue, 
brain fog, headache, loss of smell and taste, dizziness, 
shortness of breath, fever, depression, and anxiety. And in 
more severe cases, the function of critical organs like the 
heart and lungs can be affected. We have heard directly from 
long-haulers that the continuation of their symptoms as well as 
management of their care can be more of a battle than the 
initial onset of the virus, both physically and mentally.
    And early studies of long COVID are small in scale but 
raise alarming trends. One study of about 4,000 found that 
nearly 15 percent of the patients developed long COVID. The 
study also suggests that people with multiple symptoms during 
their initial infection, women, and older individuals are more 
susceptible to long COVID.
    And another recent study in Sweden found that long COVID is 
prevalent among healthcare workers. They found that 1 in 10 
young, healthy adults who initially had mild COVID symptoms 
continued to struggle with moderate to severe symptoms months 
later.
    So our goal at this hearing is to learn more about long 
COVID and what is being done to address it. On our first panel, 
we hear from leaders of two of the world's leading public 
health agencies, the National Institutes of Health and the 
Center for Disease Control and Prevention. Both agencies are 
actively monitoring long COVID and are in the process of 
expanding their research. And I look forward to hearing from 
our public health experts on that panel.
    Our second panel will include professionals on the ground 
who are treating and researching long COVID. And these doctors 
are actively working to seek out answers to many of our 
questions. And we will be joined by patients also on the second 
panel who will share their own stories about the impacts that 
long COVID have on their lives. It is important that we hear 
directly from patients as we take a close look at what is 
needed to make certain that they and other Americans with long 
COVID reach a full recovery.
    So even if a small fraction of COVID-19 patients develop 
long COVID, hundreds of thousands, if not millions, of people 
will require ongoing interdisciplinary care and may not be able 
to maintain their quality of life or their gainful employment. 
So we think it is our responsibility to ensure that we learn 
more about this, to prevent it when possible, and to help 
patients inflicted receive the proper treatment.
    I hope this hearing will help us better understand how we 
can support further research as well, but also how to prevent 
and treat those who suffer from long COVID.
    It is a very important hearing. Thank you, Madam 
Chairwoman, for doing this. I yield back.
    [The prepared statement of Mr. Pallone follows:]

             Prepared Statement of Hon. Frank Pallone, Jr.

    We have been battling COVID-19 for more than a year, and 
while much has changed in our knowledge and ability to combat 
this disease, it continues to present these new health 
challenges.
    And over 30 million Americans have tested positive for 
COVID-19 over the last year, and nearly 600,000 Americans have 
died as a result of this terrible virus. And we are always 
mindful of the toll this pandemic is taking on our families, 
friends and communities.
    Over the last year, this subcommittee has played a key role 
in responding to the ongoing public health crisis. Today, we 
continue that crucial work as we discuss a consequence of 
COVID-19 that is perplexing the scientific community. A growing 
number of individuals are experiencing the lingering effects of 
COVID-19 weeks and months after their initial infection. These 
lingering symptoms are being described as long COVID, and it 
seems to be impacting a lot of people who are otherwise 
healthy.
    A full picture of long COVID is still being drawn. 
Generally, someone is considered to have long COVID if they 
experience symptoms lasting longer than four weeks after their 
initial infection. Symptoms can include: persistent fatigue, 
brain fog, headache, loss of smell and taste, dizziness, 
shortness of breath, fever, depression, and anxiety.
    In more severe cases, the function of critical organs like 
the heart and lungs can be affected. We have heard directly 
from ``long-haulers'' that the continuation of their symptoms, 
as well as management of their care can be more of a battle 
than the initial onset of the virus--both physically and 
mentally.
    Early studies of long COVID are small in scale but raise 
alarming trends. One study of about 4,000 participants found 
that nearly 15 percent of COVID-19 patients develop long COVID. 
The study also suggested that people with multiple symptoms 
during their initial infection, women, and older individuals 
are more susceptible to long COVID. Another recent study in 
Sweden found that long COVID is prevalent among healthcare 
workers. It found that one in 10 young, healthy adults, who 
initially had mild COVID symptoms, continued to struggle with 
moderate to severe symptoms months later.
    Our goal in this hearing is to learn more about long COVID 
and what is being done to address it.
    On our first panel, we will hear from leaders of two of the 
world's leading public health agencies, the National Institutes 
of Health and the Centers for Disease Control and Prevention. 
Both agencies are actively monitoring long COVID and are in the 
process of expanding their research. I look forward to hearing 
from our public health experts on that panel.
    Our second panel will include professionals on the ground 
who are treating and researching long COVID. These doctors are 
actively working to seek out answers to many of our questions. 
And we will be joined by patients who will share their own 
stories about the impacts that long COVID is having on their 
lives. It's important that we hear directly from patients as we 
take a close look at what's needed to make certain they and the 
many other Americans with long COVID can reach a full recovery.
    So even if a small fraction of COVID-19 patients develops 
long COVID, hundreds of thousands, if not millions, of people 
will require ongoing, interdisciplinary care and may not be 
able to maintain their quality of life or their gainful 
employment. So we think it is our responsibility to ensure that 
we learn more about long COVID, to prevent it when possible, 
and to help patients inflicted receive the proper treatment.
    I hope this hearing will help us better understand not only 
how Congress can help support further research but also how 
best to help those who suffer from long COVID moving forward.
    Thank you, and I yield back.

    Ms. Eshoo. The gentleman yields back.
    The Chair now recognizes the ranking member of the full 
committee, Representative Cathy McMorris Rodgers, for her 
opening statement.

      OPENING STATEMENT OF HON. CATHY McMORRIS RODGERS, A 
    REPRESENTATIVE IN CONGRESS FROM THE STATE OF WASHINGTON

    Mrs. Rodgers. Thank you, Madam Chair. And thank you to our 
witnesses for participating and sharing your expertise today.
    The long-term effects of COVID-19 that some patients are 
experiencing is incredibly concerning. As others have stated, 
many patients have reported long-hauler symptoms like fatigue, 
brain fog, heart irregularities, chest pain, shortness of 
breath, impaired memory. Some have even experienced mental 
illness such as psychosis.
    A University of Washington study found that nearly one-
third of COVID-19 patients have reported symptoms that can 
persist for several months. This alarming statistic highlights 
the sheer scale of the potential next wave of the pandemic. We 
must have a better understanding about the causes and treatment 
for long-term COVID-19 symptoms.
    I am grateful that because of the success of Operation Warp 
Speed and the historic public-private partnerships, America has 
led to develop safe and effective vaccines that are key to 
beating this pandemic and restoring our way of life. The COVID-
19 vaccines and getting them in the arms of every American who 
wants them are vital for prevention and stopping people from 
becoming long-haulers in the first place.
    The Seattle Times recently shared Joe's story in my 
district. He was infected with COVID-19 last year and has a 
preexisting lung disease that subsided with treatment. 
Inflammation from the virus devastated his lungs, brought his 
underlying condition back, and caused irreversible damage. He 
said, quote, ``I went from being able to walk a mile quite 
easily to barely being able to walk to the restroom with 
oxygen.'' Now, a lung transplant is his only option.
    Unfortunately, there is no diagnostic mechanism for long 
COVID and there are limited treatment options. While there are 
still outstanding questions about this phenomenon, health 
providers and researchers across the country, including many in 
my State of Washington, are working hard to investigate this 
poorly understood condition.
    Researchers at Seattle's Institute for Systems Biology are 
collaborating with local healthcare providers to study and 
detect viral fragments of infection through blood tests. The 
purpose of this study is to learn more about the virus, how the 
body fights it, and the impact of infection on different 
organs.
    Other experts in my State are part of the INSPIRE study, 
which is a national collaboration conducting applied research 
to investigate the long-term outcomes of COVID-19.
    I am encouraged by this American leadership and ingenuity. 
And I am hopeful that medical experts will soon be able to 
deliver hope to patients who so desperately need it.
    COVID-19 has had devastating impacts on so many lives, 
Americans all across this country. As we safely and responsibly 
reopen and get a vaccine to every American who wants one, we 
cannot lose sight of the toll COVID-19 has on long-hauler 
patients. As we work to crush this pandemic, these patients 
deserve answers and the best care possible.
    I look forward to learning more today about what needs to 
be done to help provide relief for patients experiencing these 
symptoms.
    Thank you, and I yield back.
    [The prepared statement of Mrs. Rodgers follows:]

           Prepared Statement of Hon. Cathy McMorris Rodgers

    Thank you, Madam Chair, and thank you to our witnesses for 
participating and sharing your expertise today.
LONG-HAULERS
    The long-term effects of COVID-19 that some patients are 
experiencing is incredibly concerning.
    Many patients have reported ``long-hauler'' symptoms like
     Fatigue
     Brain fog
     Heart palpitations and chest pains
     Shortness of breath and
     Impaired memory
    Some have even experienced mental illness, such as 
psychosis.
    A University of Washington study found that nearly one-
third of COVID-19 patients have reported symptoms that can 
persist for several months.
    This alarming statistic highlights the sheer scale of the 
potential next wave of this pandemic.
    We must have a better understanding about the causes and 
treatment for long-term COVID-19 symptoms.
    I'm grateful that because of the success of Operation Warp 
Speed and the historic public-private partnerships ...
    ... America led to develop safe and effective vaccines that 
are key to beating this pandemic and restoring our way of life.
    The COVID-19 vaccines--and getting them in the arms of 
every American who wants them--are vital for prevention and 
stopping people from become long-haulers in the first place.
JOE'S STORY
    The Seattle Times recently shared Joe's story in my 
district.
    He was infected with COVID-19 last year and has a pre-
existing lung disease that subsided with treatment.
    Inflammation from the virus devastated his lungs, brought 
his underlying condition back, and caused irreversible damage.
    He said, ``I went from being able to walk a mile quite 
easily, to barely being able to walk to the restroom with 
oxygen.''
    Now, a lung transplant is his only option.
    Unfortunately, there is no diagnostic mechanism for long 
COVID and there are limited treatment options.
    While there are still outstanding questions about this 
phenomenon, health providers and researchers across the country 
...
    ... including, many in my State of Washington.
    ... are working hard to investigate this poorly understood 
condition.
WASHINGTON
    Researchers at Seattle's Institute for Systems Biology are 
collaborating with local healthcare providers to study and 
detect viral fragments of infection through blood tests.
    The purpose of the study is to learn more about the virus, 
how the body fights it, and the impact of infection on 
different organs.
    Other experts in my State are part of the INSPIRE study, 
which is a national collaboration conducting applied research 
to investigate the long-term outcomes of COVID-19.
    I am encouraged by this American leadership and ingenuity, 
and I am hopeful that medical experts will soon be able to 
deliver hope to patients who so desperately need it.
CONCLUSION
    COVID-19 has had a devastating impact on the lives of so 
many Americans.
    As we safely and responsibly reopen and get a vaccine to 
every American who wants one ...
    ... we cannot lose sight of the toll COVID-19 has on long-
hauler patients.
    As we work to crush this pandemic, these patients deserve 
answers and the best care possible.
    I am looking to learning more today about what needs to be 
done to help provide relief for patients experiencing these 
debilitating symptoms.
    Thank you and I yield back.

    Ms. Eshoo. The gentlewoman yields back.
    The Chair would like to remind Members that, pursuant to 
committee rules, all Members' written opening statements will 
be made part of the record.
    I now would like to introduce our witnesses for our first 
panel, a distinguished panel. First--he doesn't need any 
introduction to us, I don't think to the American people, 
because his name is synonymous with hope--from the National 
Institutes of Health, Dr. Francis Collins. He is the Director 
of the NIH.
    We welcome you back to the committee, Dr. Collins, and we 
are very grateful to you for being with us today.
    We are also joined by Dr. John T. Brooks. He is the chief 
medical officer of the CDC COVID-19 Response.
    Welcome, Dr. Brooks, and thank you for joining us.
    So, Dr. Collins, you have--you are recognized for your 
statement. And, again, thank you for the extraordinary work 
that has taken place at the NIH, especially over this last year 
that has been so challenging for everyone. And we are very 
anxious to hear from you because this is an issue that is 
having great impact, taking a toll on our fellow Americans. And 
we know that you are going to help guide us with producing an 
answer. So welcome again to the subcommittee. You are now 
recognized.

  STATEMENTS OF FRANCIS S. COLLINS, M.D., DIRECTOR, NATIONAL 
INSTITUTES OF HEALTH, DEPARTMENT OF HEALTH AND HUMAN SERVICES, 
 AND JOHN T. BROOKS, M.D., CHIEF MEDICAL OFFICER, CDC COVID-19 
     RESPONSE, CENTERS FOR DISEASE CONTROL AND PREVENTION, 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES

             STATEMENT OF FRANCIS S. COLLINS, M.D.

    Dr. Collins. Well, thank you.
    Good morning, Chair Eshoo and Ranking Member Guthrie, full 
committee Chair Pallone and Ranking Member McMorris Rodgers, 
and distinguished subcommittee members. I don't know that I can 
recall being at a hearing with this much interest and this many 
Members attending in a long time.
    Thank you all for your sustained commitment to the National 
Institutes of Health, the NIH. I am really grateful for this 
opportunity to discuss how NIH research is addressing this 
major public health concern commonly known as long COVID.
    We have heard troubling stories--all of us have--of people 
who are still suffering months after they first came down with 
COVID-19, some of whom initially had very few symptoms or even 
none at all. And yet today, these folks are coping with a long 
list of persistent problems affecting many different parts of 
the body: fatigue, brain fog, disturbed sleep, shortness of 
breath, palpitations, persistent loss of taste and smell, 
muscle and joint pain, depression, and many more.
    Late last year, we began to talk with congressional 
leaders, including many of you, about the substantial research 
needed both to understand long COVID and to discover ways of 
treating and preventing it. You immediately grasped the 
importance of this issue, appropriating more than $1 billion 
for this work in December. Since then, we have pulled together 
experts from many scientific fields to design a fast, flexible 
research initiative. In a moment, I will walk you through our 
plans. But, first, I would like to speak directly to the 
patient community.
    Some of you have been suffering for more than a year with 
no answers, no treatment options, not even a forecast of what 
your future may hold. Some of you have even faced skepticism 
about whether your symptoms are real. I want to assure you that 
we at NIH hear you and believe you. If you hear nothing else 
today, hear that we are working to get answers that will lead 
to ways to relieve your suffering.
    Now on to our research plans. We need to start by 
understanding the basics. New data arrive every day, but 
preliminary reports suggest that somewhere between 10 to 30 
percent of people infected with SARS-CoV-2 may develop longer-
term health issues.
    To get a solid measure of the prevalence, severity, and 
persistence of long COVID, we really need to study tens of 
thousands of patients. And these folks should be diverse, not 
just in terms of the severity of their symptoms and type of 
treatment received, but in age, sex, race, and ethnicity. To do 
this rapidly, we are launching an unprecedented metacohort.
    What is that? Well, an important part of this can be built 
on existing longitudinal community-based cohorts or also the 
electronic health records of large healthcare systems. These 
resources already include tens of thousands of participants who 
have already contributed years worth of medical data. Many of 
them will by now suffer from long COVID.
    This approach will enable us to hit the ground running, 
giving researchers access to existing data that can quickly 
provide valuable insights on who might be most at risk, how 
frequently individual symptoms occur, and how long they last.
    Individuals suffering with long COVID, including those from 
patient-led collaborative groups, will be invited to take part 
in intensive investigation of different organ systems to 
understand the biology of those symptoms. Our goal is to 
identify promising therapies and then test them in these 
volunteers.
    We also want to learn from following cohorts of patients 
with COVID who were enrolled in therapeutic trials for their 
acute illness. Do they get long COVID? Does the therapeutic 
they were given change that outcome? They are already being 
meticulously monitored, with researchers recording clinical 
data and, in many cases, participants providing detailed 
observations about their own health status.
    Finally, we need a cohort for children and adolescents. 
That is because kids can also suffer from long COVID. And we 
need to learn more about how that affects their development.
    We have already had 273 responses to our call for research 
proposals. And we expect to make awards in the next 3 weeks. 
Intensive laboratory and imaging studies should be underway by 
summer. Patients will have an active role at every level and 
stage of this research. As we recruit volunteers, we will ask 
them to share their health information real-time with mobile 
health apps and wearable devices.
    Long COVID and the people living with it can no longer be a 
hidden toll of the pandemic. We must bring them to the 
forefront of our fight against COVID-19 and pursue with all the 
energy that we can muster the answers and the interventions 
that will help them.
    In closing, I would like to emphasize that one critical way 
to prevent long COVID is to prevent COVID itself. Even for 
young people who consider their risk of severe COVID to be low, 
the long-term consequences can be quite serious. So long COVID 
represents one more reason to encourage everyone age 16 and 
over to get vaccinated as quickly as possible.
    Thank you, and I look forward to your questions.
    [The prepared statement of Dr. Collins follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you, Dr. Collins, for your excellent 
opening statement. And I know that Members are anxious to field 
their questions to you, but you gave us a great overview.
    The Chair now recognizes Dr. Collins for--Dr. Brooks, I am 
sorry--for 5 minutes.

               STATEMENT OF JOHN T. BROOKS, M.D.

    Dr. Brooks. Thank you.
    And good morning, Chairwoman Eshoo and Ranking Member 
Guthrie and all the committee members, for the invitation to 
talk with you today.
    Over the last year, I have had the honor of serving as 
chief medical officer for CDC's COVID-19 Response. But before I 
begin, I want to take a moment today to just recognize the 
nearly 570,000 American lives lost to this virus. I also want 
to recognize the tens of millions of Americans who have 
survived COVID-19 but now face serious challenges and 
uncertainty with post-COVID conditions which are real and 
concerning.
    You are why we are here today. I and my colleagues have 
heard you. I am here today with others to share what we know 
about what it is that you are experiencing, because we are 
committed to helping you.
    As a physician myself, I also know how challenging and 
worrisome these conditions are to the healthcare providers 
across our Nation who are seeing more and more patients in 
clinic with ongoing challenges after COVID infection.
    I am also grateful for this opportunity to discuss the 
impact of these conditions and to review CDC's efforts to study 
them, measure their prevalence and severity, identify persons 
at increased risk, and develop recommendations for their 
prevention and treatment.
    Although standardized case definitions are still being 
developed, CDC uses the umbrella term ``post-COVID conditions'' 
to describe health issues that persist for more than 4 weeks 
after a person is first infected with SARS-CoV-2, the virus 
that causes COVID-19. Based on our studies to date, CDC has 
distinguished three general types or categories of post-COVID 
conditions, although I want to caution that the names and 
classifications may change as we learn more.
    The first, called long COVID, involves a range of symptoms 
that can last for months. The second comprises long-term damage 
to one or more body systems or an organ. And the third consists 
of complications from prolonged treatment or hospitalization.
    As in all of our work, CDC is committed to addressing post-
COVID conditions through a lens of health equity. While we 
don't yet have clear data on the impact of post-COVID 
conditions on racial and ethnic minority populations and 
underresourced communities, we are working to enhance the 
collection of demographic data to inform our knowledge base and 
resulting guidance.
    As these groups are both more likely to acquire infection 
and less likely to be able to access healthcare services, we 
believe they are disproportionately affected by these 
conditions.
    As early as the spring of 2020, CDC initiated studies to 
understand the nature of these emerging conditions that follow 
recovery from infection and to assess their contribution to the 
burden of disease among survivors. Among these efforts are 
prospective studies that will follow cohorts of patients for up 
to 2 years to provide information on the proportion of people 
who develop post-COVID conditions and assess risk factors for 
their development.
    CDC is also working with multiple partners to conduct 
online surveys about long-term symptoms and using multiple 
deidentified electronic health record databases to examine 
healthcare utilization of patient populations after initial 
infection. The collection of these data informs our 
understanding how often post-COVID conditions develop and how 
long they may be expected to last.
    CDC is also working on interim evidence-based guidance, 
conducting calls to raise awareness among clinicians and 
educate them and publishing studies with data for action, with 
a focus on equipping primary care providers with information on 
diagnosis and management to the extent that is presently 
available. We regularly solicit feedback from these national 
clinical organizations to ensure this guidance is informative 
and up to date.
    CDC is also working to identify potential long-term 
surveillance possibilities, including leveraging existing 
systems and research.
    In closing, CDC is committed to working hand-in-hand with 
NIH, research partners, healthcare providers, and the affected 
patients and their advocates across all levels of government to 
advance the science around post-COVID conditions to more fully 
understand these conditions and ultimately help the people 
experiencing them. We will continue to provide guidance on 
post-COVID conditions that is rooted in science, maintaining 
transparency about what we know and also what we do not know, 
and updating our guidance as evidence evolves. And we will keep 
health equity at the forefront of our efforts to address post-
COVID conditions.
    While a lot of work has already begun to address post-COVID 
conditions, we know there is much left to do to create the 
evidence base needed to help people suffering with these 
conditions. I really look forward to working together towards 
that end.
    Thank you again for the invitation to testify today, and I 
welcome your questions.
    [The prepared statement of Dr. Brooks follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you very much, Dr. Brooks. And we are so 
pleased to have you with us today as a witness.
    We are now going to move to Member questions. And I 
recognize myself for 5 minutes to do so.
    To Dr. Collins and Dr. Brooks: The Biden administration has 
developed a really wide-ranging, whole-of-government response 
to the acute impacts of COVID-19, including the formation of 
the White House COVID Response Team, the COVID Health Equity 
Task Force, but I don't think there has yet been a similarly 
public coordinated and comprehensive effort to address, you 
know, this multifaceted issue that we are having the hearing on 
today. Because it is--as you both noted, it is a crisis for 
patients, has an effect on our healthcare system, and there are 
so many issues that are attached to this.
    What I would like to know is, who is in charge of leading 
this effort? In listening to your testimonies, you are both in 
the same lane. But is there one person or one outfit or one 
task force in charge of this? Maybe it is a yes-or-no answer, I 
don't know.
    Dr. Collins. It is a very appropriate question. I think we 
have excellent relationships between NIH and CDC. Dr. Brooks 
works intensively with Dr. Lerner and my staff. We are working 
with FDA also in this space and also with CMS. But you are 
right, there is no sort of supervisory, top-level oversight 
like there is----
    Ms. Eshoo. Do you think, Dr. Collins, we need one?
    Dr. Collins. You know, I have to think hard about it, 
because sometimes----
    Ms. Eshoo. OK.
    Dr. Collins [continuing]. It can be a good thing or 
sometimes it can kind of get in the way of a more organic 
approach.
    Dr. Brooks, go ahead.
    Dr. Brooks. Yes. I just wanted to add that I would say 
that, first of all, we are collaborating intensively. And this 
is sort of standard for how we often address these emerging 
problems, you know, that we work hand-in-hand very closely on 
both the natural history and epidemiology side, together with 
the clinical side, because both are needed for a coordinated 
response. And we have regular calls with NIH.
    At this time, you know, we would have to think about 
whether a coordinating body is necessary. I think we are 
working very well right now together.
    We also--you had asked about sort of other government 
engagement. I just would say a couple of things to that. While 
we are in the preliminary phases of really beginning to define 
what this is, it may be some time before we have a lot to bring 
to some of these other groups, particularly groups like HRSA to 
trot this out.
    I will say, though, we have already been in touch with CMS 
about case definitions as well as the Social Security 
Administration.
    Ms. Eshoo. OK. Well, Dr. Collins--well, thank you, Dr. 
Brooks, for that.
    I think that there are a lot--we have patients with us 
today. And thank you, Dr. Collins, for in your opening, in your 
testimony, you spoke directly to patients across the country.
    Now, you also spoke about metacohort undertakings. When do 
you expect that to conclude? How long is that going to take? 
And in the meantime, what can NIH, CDC, FDA, the 
administration, the Congress, what do we tell our constituents 
that are undergoing what is attached to this condition?
    Dr. Collins. So the timetable we are moving forward with is 
pretty unprecedented for such a large-scale study, but it needs 
to be. The funding you all provided was made available in 
December. By February, we put out a notice to all of the 
organizations and academic centers and other entities that we 
thought could help with this. And we got a response of that 273 
applications that are currently going through an intense 
review. We aim to make those awards within the next 3 weeks and 
to stand up this metacohort in a series of core facilities so 
that we can immediately begin the process of collecting the 
data. And doing a deeper dive into trying to understand really 
what is the mechanism that is causing this illness.
    And one thing, I guess, we will be depending on the patient 
groups is participation in those research studies. And I think 
I am hearing a lot of motivation for that, so I think we are 
going to have wonderful partnerships. And we want them at the 
table for every decision we make. This is not supposed to be a 
top-down, but more of a bottom-up effort to get answers----
    Ms. Eshoo. Thank you very much. Oh, I think my time has 
been used.
    And so the Chair will now recognize Mr. Guthrie, the 
ranking member of our subcommittee. You are recognized for your 
5 minutes of questions.
    Mr. Guthrie. Thanks, Chair Eshoo. And thanks to our 
witnesses here today.
    And, Dr. Collins, first off, I heard your message a few 
Sundays ago on ``CBS Sunday Morning,'' and in here, and all 
times I have dealt with you. And, Dr. Brooks, I haven't dealt 
with you as much, so I am sure this is appropriate as well. 
But, you know, the tone in which you speak about testing is 
important. We have a lot of information, but we don't need to 
come off like we think we are smarter than everybody else, even 
though we have more information than people have. And so as we 
share that, I think the way we speak to people is how they 
listen to us. And I think your tone on that message you put on 
that Sunday morning about being vaccinated was just absolutely 
the right way we need to speak to people. So thank you for 
that.
    Speaking of vaccinations, Dr. Collins, I have heard through 
anecdotal reports that people who have long-term COVID are 
experiencing improvement after they are vaccinated in their 
conditions. Can you speak more to this, and what do you think 
is causing this reaction?
    Dr. Collins. It is a great question. There have been 
anecdotal reports of people who suffered for months sometimes 
with long COVID, and after getting the COVID vaccine 
[inaudible]--a bit of a background there. Well, I guess I will 
just keep talking --have reported benefit, in some instances, 
fairly dramatic benefit within a few days.
    It is hard to get really good data. The largest study that 
has actually been published in a preprint was only 44 
individuals who had in fact had long COVID, got vaccinated, and 
there was overall a tendency towards improvement. Something 
like 23 percent of them said they were better after a month, 
whereas those who didn't get the vaccine, it was 15 percent. So 
it is a small difference. We need to understand that.
    One of the questions is, how would that work anyway? Does 
that say that there is still lingering infection by the SARS-
CoV-2 virus in people with long COVID? Even though we have not 
been able to recover the virus from those folks, does the 
vaccine giving this response say that there is some sort of 
reservoir there? That is a clue. So it is one of the more 
interesting things that has come along recently. It might be a 
possible way to go forward.
    This is one of the reasons we really need to have this much 
larger-scale metacohort to try to get an answer to whether this 
is a real signal or not. So we are all over it.
    Mr. Guthrie. Well, thank you very much. That is great to 
hear.
    And, Dr. Brooks, a recent study of COVID patients found 
that nearly 13 percent received their COVID-19 diagnosis for 
the first time were presenting with long-COVID symptoms. 
Presumably, these people first had COVID either when testing 
was not prevalent or had asymptomatic or mild cases.
    How can we diagnose more of these long-COVID cases earlier? 
And is there a role for serology testing? And what other 
diagnostics are needed to better identify long COVID?
    Dr. Brooks. Thank you very much for asking that question. 
You raise a really important point, which is, not only are 
there persons who develop post-COVID symptoms who we later 
through serology or testing recognize as having had COVID, but 
there are also people who develop these post-COVID conditions 
who have no record of testing and we can't determine if they 
had COVID. So we have got to think carefully about what that--
how to manage that when we are coming up with a definition for 
what a post-COVID condition is.
    But more to the point of your question, the most important 
thing as I think was first laid out is to just get vaccinated 
and avoid getting the infection in the first place. If, 
however, you experience the infection and develop post-COVID 
conditions, one of the most important things is to make sure 
that this condition is recognized. We need to make sure that 
folks know what they are looking at.
    As you have heard, it is sort of protean, there are all 
sorts of different ways, and maybe we will talk about this 
later, but the symptoms and ways that people present are very 
varied. And people need to be thinking, could this be post-
COVID, and also taking patients at their word. You know, we 
have heard many times that patients have been ignored or their 
symptoms minimized, possibly because they didn't recognize they 
had COVID previously.
    Mr. Guthrie. OK. Thank you.
    And then, Dr. Collins, how is NIH leveraging existing 
longitudinal community-based cohorts such as the All of Us 
Study to examine and study long COVID? And what more can be 
done to study these individuals?
    Dr. Collins. That is a great question. All of Us, you may 
know, is this large-scale study, very diverse in those who have 
enrolled in it, aiming to have a million Americans that we can 
follow over time for all kinds of questions that could be asked 
at length about how to prevent illness or how to manage chronic 
disease.
    We are already up to over 300,000 participants. I think 
some of you are participants. Thank you, if you are. And this 
is a golden opportunity because these are individuals who have 
consented to be part of research. They are enthusiastic about 
it. They are our partners. And with 300,000-plus of them, there 
have been lots of people who have had COVID and quite a few who 
are now suffering from long COVID. And we have this historical 
information about them prior to their being exposed to this 
virus. So we can really look at the sweep of their experience 
and perhaps identify what were the predisposing factors that 
caused those people who get the acute illness to go on to long 
COVID and not just get better the way most respiratory viruses 
ought to do.
    So that is part of our metacohort, a very exciting part or 
our metacohort. We are going to build on that as well by 
enrolling other folks with other backgrounds, but I am glad you 
raised that one.
    Mr. Guthrie. Thank you very much.
    And thanks, Chair. I yield back.
    Ms. Eshoo. The gentleman yields back.
    It is a pleasure to recognize the chairman of the full 
committee, Mr. Pallone, for his 5 minutes of questions.
    Mr. Pallone. Thank you, Madam Chair.
    And let me say how pleased I am to have Dr. Collins and Dr. 
Brooks here today to discuss the long-COVID issue.
    I think that you have touched a little bit on some of my 
questions, so maybe we can just ask you to develop some more 
details.
    Let me start with Dr. Brooks. I know you touched upon the 
strides that the CDC has been making in addressing the pandemic 
in the short and long term, and you talked about the incidence 
and prevalence of long COVID so far. But just share with me a 
little more details about what you have been able to understand 
about the incidence and prevalence of long COVID so far, if you 
will.
    He may be on mute. Maybe I am on mute.
    Dr. Brooks. My apologies. My Christmas card is going to be 
``I am on mute.''
    OK. Thank you. I am happy to share with you what we know 
about this. As I mentioned, we have been doing some cohort 
studies since early last spring. These and some of our analyses 
of electronic health records have given us some insight into 
the potential incidence of post-COVID conditions. That together 
with also external research that others have cited already lead 
us to believe that, one, it is common. It could be as common as 
two out of every three patients.
    A study we recently published in our flagship journal, the 
Morbidity and Mortality Weekly Report, suggested two out of 
three patients made a clinical visit within 1 to 6 months after 
their COVID diagnosis. So that is unprecedented. People who 
recover from the flu or a cold don't typically make a scheduled 
visit a month later. It does seem that for some people the 
condition gets better, but there are definitely a substantial 
fraction of persons in whom this is going on for months.
    The value of the study that Dr. Collins spoke to is that 
with the large numbers it will really help us hone in more 
closely on what the precise numbers look like.
    Mr. Pallone. Well, thank you. And I know you, both of you, 
have mentioned this metacohort study, which maybe you can 
explain what metacohort means, and then, you know, how that is 
going to help us get a more reliable measure of how widespread 
this long COVID might be, Dr. Collins.
    Dr. Collins. Yes. Let me give a try at that. Yes, maybe 
that is not such a familiar word. Even for people who do 
epidemiology, we haven't had a lot of metacohorts, so let me 
explain.
    Basically, what we did was to think of all of the ways in 
which we could try to get answers to this condition by studying 
people, both those who already have self-identified as having 
long COVID as well as people who just went through the 
experience of having the acute illness, to see what is the 
frequency with which they ended up with these persistent 
symptoms. And if you look around sort of what would be the 
places where you would find such large-scale studies, one would 
be, like we were just talking about a minute ago with Mr. 
Guthrie, the idea of these long-standing cohort studies, 
Framingham being another one, where you have lots of people who 
have been followed for a long time, see if you can learn from 
them who got long COVID and what might have been a predisposing 
factor. That is part of the metacohort.
    You could also look at people who have been in our 
treatment trials, because there are thousands of them that have 
enrolled in these clinical trials, and they got a particular 
treatment applied, like a monoclonal antibody, for instance. It 
would be really interesting to see if that had an effect on how 
many people ended up with long COVID. Did you prevent it if you 
treated somebody acutely with a monoclonal antibody?
    And then there are all these patient support groups, and 
you will be hearing more from them in the second panel, were 
highly motivated, already have collected a lot of data 
themselves as citizen scientists. We want to tap into that 
experience and that wise advice about how to design and go 
through the appropriate testing of all this.
    So you put those all together and that is a metacohort, 
where you have different kinds of populations that are all put 
together in a highly organized way, with a shared database and 
a shared set of common data elements, so we can learn as 
quickly as possible. Theoretically, we can just do one of 
those, but this is such an urgent crisis, and you the Congress 
have given us enough resources. We are trying to do all of them 
but in a seamless, integrated, synergistic way.
    Mr. Pallone. Thank you.
    Could you just quickly, Dr. Brooks, tell us about how CDC 
is planning to keep providers informed on how to diagnose and 
treat patients with long COVID? There is only like 20 seconds 
left, if you could quickly.
    Dr. Brooks. Yes. First, we do webinars and regular calls, 
updating them on what we know, publishing interim guidance that 
we regularly update. And that guidance is informed, not only by 
clinical providers, but also by patient groups with whom we 
share the information.
    Mr. Pallone. All right. Thanks a lot.
    Thank you, Madam Chair.
    Ms. Eshoo. The chairman yields back.
    And the Chair now recognizes the ranking member of the full 
committee, Congresswoman Cathy McMorris Rodgers, for her 5 
minutes of questions.
    Mrs. Rodgers. Thank you, Madam Chair. Thank you. Thank you, 
everyone.
    I wanted to start with a question to Dr. Collins. And 
really appreciate both Dr. Collins and Dr. Brooks being with us 
today. This is extremely helpful. I wanted to take a moment 
just to ask a question about a letter that Congressman Morgan 
Griffith and Congressman Brett Guthrie and I had sent to NIH 
back in March, March 18, that was really about understanding 
the origins of the pandemic. And I understand that NIH is 
working on a response. And I want to thank you for your 
attention.
    The question is, do you believe that it is in the public 
interest to have a comprehensive, scientific investigation into 
the pandemic origins? And do you agree with the Director-
General of the World Health Organization that further 
investigation into COVID origins is needed, including reviewing 
possible links to the potential laboratory leak?
    Dr. Collins. Yes, I do believe that an investigation 
following on the original WHO investigation is needed. You may 
have seen The Wall Street Journal report just yesterday 
indicating that there is a serious effort now within the U.S. 
Government, between the State Department, the Department of 
Health and Human Services, the Department of Agriculture, and 
five other Federal agencies to put forward to WHO what we 
believe ought to be the components of such a followup 
investigation. It should be science based. It should be looking 
at evidence. It should be rigorous. It should try to get 
answers to the questions that the first investigation was not 
able to derive. And NIH will undoubtedly play some role in 
that, although it obviously is occurring at the Department 
level.
    So yes. To answer your question directly, we do believe 
that a followup investigation is appropriate. And we are 
working on answers to your letter with 29 questions and 40 
footnotes and 11 pages. It is taking us a little longer than a 
few days.
    Mrs. Rodgers. Yes, I understand that. It is very 
comprehensive. I appreciate your attention to those questions.
    I also wanted to ask about children. And I think we are 
learning that children are better protected from some of the 
most severe symptoms of COVID-19. However, it is becoming 
increasingly apparent that some children who have contracted 
COVID-19 are having long-term effects. And would you just speak 
to what we know about long COVID in children? And can you tell 
us about the special cohort that the NIH is developing for 
children and adolescents?
    Dr. Collins. Yes. And I really appreciate that question, 
because this is another critical part of the metacohort that I 
failed to mention a minute ago and should have.
    We do know that children can get long COVID. In fact, the 
harder you look, it seems, at least in the study that I think 
that has done the most thorough job so far, that somewhere 
around 11 to 15 percent of kids who have had the COVID 
infection, and they are not immune to it, can end up with this 
long-term consequence, which can be pretty devastating in terms 
of things like school performance. So we need to understand 
that as well.
    Just to clarify: There is a separate problem that children 
who have had COVID-19 can have, which is something called MIS-
C, multisystem inflammatory syndrome of children, which is an 
autoimmune, a rather dramatic condition which can put kids in 
the ICU, which we do know how to treat. And that is a critical 
one as well, but I think it is a different pathogenesis than 
the long COVID.
    The long COVID cases look kind of like the adult cases, 
except they are in younger individuals. So as part of studying 
this we need to include children in a very significant way and 
collect all the data that we can and try to understand the 
cause.
    Mrs. Rodgers. Thank you very much. And I appreciate your 
attention to that.
    Dr. Brooks, you say that COVID infection is not unique in 
terms of causing both an acute illness followed by longer-term 
conditions and that some post-COVID conditions may be similar 
to those in other diseases. Would you just speak to what post-
COVID conditions are similar to those seen in other infectious 
diseases? And can we learn anything from those diseases that 
would help our understanding of long COVID?
    Dr. Brooks. Yes, happy to. So I think the complications 
that are seen in the post-COVID conditions to which the 
parallel is often most rapidly drawn is to myalgic 
encephalitis, or chronic fatigue syndrome. Let me be very 
cautious there and say that that is usually--we often jump to 
framing something, when it is new, to frame it with something 
we already know. And I want to stress that we now also know 
that what we are seeing with post-COVID differs from that set 
of conditions.
    What it shares in common, particularly in people who have 
this for months, are extreme fatigue. I mean fatigue, as you 
probably heard, so bad you can't get out of bed, it makes it 
impossible for you to work and limits your social life. Anxiety 
and depression lingering, chronic difficulty breathing, with 
either cough or shortness of breath. The loss of smell persists 
for a very long time, which, incidentally, is particularly 
unique to this infection, the best I know.
    What I would like to stress is that what we are doing now 
to understand post-COVID conditions may well have benefits for 
other conditions like it. It is a leading hypothesis, I think, 
that myalgic encephalitis is caused by an infectious disease 
insult, but we don't really know the timing and how it occurs.
    The cohorts that Dr. Collins described, where we are 
following people in real time already and that we can see them 
when they get COVID and follow them forward, we have a unique 
opportunity to really begin to understand what the interplay 
may be between this insult, if you will, from an infection and 
how that results in these conditions later. And then use that 
to identify people at risk, predict who may get it, and better 
understand how to treat it.
    Mrs. Rodgers. Super. Thank you very much. Thank you both.
    I yield back.
    Ms. Eshoo. The gentlewoman yields back.
    It is a pleasure to recognize the gentleman from North 
Carolina, Mr. Butterfield, for your 5 minutes of questions.
    Mr. Butterfield. Thank you very much, Madam Chair. And good 
to see all of you today and hope you are doing well.
    Let me first start with Dr. Brooks. Dr. Brooks, thank you 
for your testimony. The evidence from the past year clearly 
shows that COVID is disproportionately harming African 
Americans, Latinos, and Native communities. In your testimony, 
you note that because of the higher rate of COVID cases in 
these communities, it is likely that these communities will 
also experience post-COVID conditions at a higher rate.
    And so my question is, data can be a powerful tool. Is the 
CDC tracking race and ethnicity in its long-term studies, long-
term studies that have worked utilizing data from electronic 
health records and online surveys? And if not, let me ask you, 
why? And how can those challenges be fixed?
    Dr. Brooks. Well, thank you for raising that question. I 
think this may be a short answer, which is, absolutely, we are 
following race, ethnicity, as well as often income, educational 
attainment, and other social determinants of health in the 
studies that we are doing related to COVID.
    I would like to point out that one of the cohort studies we 
are doing is particularly focused on American Indians and 
Alaska Natives. Others are oversampling racial or ethnic 
minority populations or those who are underresourced to ensure 
that we get information about these communities.
    One point I would like to make is electronic health records 
can be a little tricky, because it depends on what the 
clinician entered as the race or ethnicity. And in some of our 
studies, we have the opportunity to ask people themselves, tell 
us how you want us to represent you in this study. And it is 
nice when we are able do that.
    Mr. Butterfield. Thank you. Thank you for that response.
    And now I will go to my good friend Dr. Collins. It is good 
to see you, Dr. Collins. And thank you for your incredible 
work.
    In your testimony, Dr. Collins, you describe taking 
advantage of existing cohort and clinical studies to create a 
megacohort to compare post-COVID conditions data. You note that 
for this effort to be effective, the data must be standardized.
    My question is about standardization. Can you explain how 
the NIH is planning to address the standardization issue and 
whether you see any other barriers that would prevent 
megacohort data from being used effectively?
    Dr. Collins. That is a great question, Congressman. Yes, it 
is both a metacohort and, as you have said, it is a megacohort 
as well. We can use the T or the G and they would both be 
correct.
    So the idea of trying to assemble such a large-scale effort 
from multiple different kinds of populations of patients is our 
idea about how to do this quickly and as vigorously and 
accurately as possible. But it won't work if we can't actually 
compare across studies and figure out what we are looking at.
    So part of this is the ability to define what we call 
common data elements, where the individuals who are going to be 
enrolled in these trials from various sources have the same 
data collected, using the same format, so that you can actually 
say if somebody had shortness of breath, how did you define 
that? If somebody had some abnormality in a lab test, what were 
the units of the lab test that everybody will agree so you can 
do apples-to-apples comparisons? That is already underway.
    Part of this metacohort is also to have three core 
facilities. One of those is a clinical sciences core, which 
will basically come up with what are the clinical measures that 
we want to be sure we do accurately on everybody who is 
available for those to be done.
    Another is a data sciences core, which will work 
intensively on these common data elements and how to build a 
data set that is both preserving the privacy and 
confidentiality of the participants, because these are people 
who are human subject participants in a trial, and also making 
sure that researchers have access to information that they can 
quickly learn from.
    Then there is a third core, which is a bio repository, 
where we are going to be obtaining blood samples and other 
kinds of samples, and we want to be sure those are accurately 
and safely stored so they can be utilized for follow-up 
research. All of that has to fold into this.
    And so I am glad you asked the question. That is the 
mechanism by which we aim to make the whole greater than the 
sum of the parts here. Even though the parts are pretty 
impressive, the whole is going it to be pretty amazing.
    Mr. Butterfield. Thank you. Thank you very much, Dr. 
Collins. And we are going to continue to support your work on 
this committee. And, again, thank you. And thank you to all of 
your colleagues at the agency. You are doing incredible work. 
And let's hope the President tonight will also recognize your 
great work. Thank you.
    I yield back.
    Ms. Eshoo. I think he recognized Dr. Collins' great work 
because he was one of the first individuals that he called and 
said, ``We need you to stay.'' So thank you.
    The gentleman yields back.
    A pleasure to recognize a former chairman of the full 
committee, a great friend to all of us, Mr. Upton from 
Michigan.
    Mr. Upton. Well, thanks, Madam Chair. It is a little bit of 
a cold, rainy day back here in Michigan, but I am delighted to 
be here with all of you, and certainly my very good friend Dr. 
Collins, a University of Michigan former professor before he 
moved forward and has done great work. And I have got a Bo 
Shembechler bobblehead right behind me if you look carefully.
    But let me just--I want to focus on a couple of things with 
you as we move forward. You know, you and I talked a lot last 
year about the RADx program, which was part of the first COVID 
package that we adopted on a very strong bipartisan vote, over 
400 votes. It speeds up the innovation and the development to 
commercialization and implementation of testing for COVID.
    So what has NIH learned literally in a year since the 
launch of that program where you put it together, I want to 
say, over a weekend. But what did you learn that can help us as 
we move forward, particularly as we have now made real progress 
with the vaccines, but we have a long way to go still in the 
years ahead?
    Dr. Collins. Well, thank you for that question, and, yes, 
for your support of RADx. Yes, it is interesting you ask the 
question, because tomorrow is the 1-year anniversary of the 
launch of RADx, Rapid Acceleration and Diagnostics, another 
program made possible by the Congress by providing us with some 
additional funds to be able to build new platforms for 
technology to detect the presence of that SARS-CoV-2 virus, 
increasingly being able to do those now as point of care 
instead of having to send your sample off to a central 
laboratory and even now doing home testing, which has now just 
in the last month or so become a reality, and that is RADx that 
developed those platforms.
    It was a pretty amazing experience, actually. We basically 
built what we called a shark tank. We became venture 
capitalists. And we invited all of those people who had really 
interesting technology ideas to bring them forward. And the 
ones that looked most promising got into the shark tank and got 
checked out by business people, engineers, various other kinds 
of technology experts, people who knew about supply chains and 
manufacturing and all of that to make sure that we put the 
funds into the ones that were most promising.
    And right now today, Congressman, there's about 2 million 
tests being done today as a result of RADx that otherwise would 
not have been. Two million a day. Thirty-four different 
technologies that we put through this innovation funnel. And 
that has opened up a lot of possibilities for things like 
getting people back to school, where you have testing capacity 
that we didn't have before.
    What did we learn about that that applies to long COVID? 
Well, one thing I learned was we can do things at NIH in really 
novel ways that move very quickly when we are faced with a 
crisis like COVID-19 pandemic. We are applying that same 
mentality to this effort on long COVID.
    Normally, it would have taken us more than a year to set up 
this kind of metacohort. We are doing it in a couple of months 
because we need to. Utilizing some of those same mechanisms 
that you gave us in the 21st Century Cures bill, which has been 
a critical part of our ability to move swiftly through 
something called Other Transactions Authority. So, yes, we have 
learned that.
    And by the way, I have to put a little plug here, if you 
saw in the President's budget proposal for fiscal year 2022 
something called ARPA-H, which is basically bringing the DARPA 
attitude to health. That also builds on these experiences and 
will give us, if approved by the Congress, the ability to do 
even more of these very rapid, very ambitious, yes, high-risk 
but high-reward efforts as we have learned to do in the face of 
COVID and want to continue to do for other things, like 
Alzheimer's disease or cancer or diabetes, because there's lots 
of opportunities there too.
    Mr. Upton. Well, even though I will be in Michigan tonight 
and not on the House floor, I know that work on ARPA-H, but 
Chairwoman Eshoo and myself and Diana DeGette were meeting with 
the President a little bit more than a month ago, and we talked 
about ARPA-H. I acknowledge and support the promise that this 
may really provide as we go to the next level. And I would 
suspect, I would hope, that the President will talk about it 
this evening and that we, in fact, can come back--as you know, 
we are looking at a CARES 2.0 bill, and this would be an 
element of that that we pledge to work with the President on 
that. And I think it can be very, very positive and 
constructive, not only for us but for the entire world. And I 
appreciate your leadership on that and your good work and look 
forward to working with you in the months ahead.
    And, with that, my time is expired.
    I yield back.
    Ms. Eshoo. The gentleman yields back.
    And I appreciate what you just said about ARPA-H. That 
meeting with the President was bipartisan, obviously, it was 
bicameral, and I think shoulder-to-shoulder that this effort 
can really move the needle in very important and overarching 
ways for people in our country and for the world.
    So it really was uplifting and is to be a part of that 
effort. And the gentleman has a history of leading on these 
issues. So thank you.
    The Chair now recognizes the gentlewoman from California, 
Ms. Matsui, for her 5 minutes of questions. Great to see you, 
Doris.
    Ms. Matsui. You too.
    Thank you very much, Madam Chair. And thank you for this 
hearing, and I want to welcome Dr. Collins and Dr. Brooks for 
joining us this morning on this very important hearing.
    While primarily it was a respiratory disease, we know that 
COVID-19 can also lead to neurological problems. To investigate 
these problems, researchers at NIH National Institutes of 
Neurological Disorders conducted the first indepth examinations 
of human brain tissue samples from people who died after 
contracting COVID-19.
    Now, Dr. Collins--and it is great to see you--can you talk 
a bit about the findings from this NIH study, and what did it 
suggest about the likely explanation for COVID-19's many 
neurological symptoms?
    Dr. Collins. Thanks for the question, Congresswoman Matsui.
    This was work done by our investigator in our intramural 
program, Dr. Avindra Nath, and he was looking at brain samples 
from individuals who had died, many of them suddenly and 
unexpectedly. These weren't necessarily people who had been in 
the hospital a long time. Some of them never were hospitalized 
and then had sudden death.
    And he looked very carefully to see what was happening and 
found that there was evidence not actually that the virus 
itself was present in the brain. It was not possible to find 
the actual viral proteins or the viral RNA, but instead a lot 
of damage seemed to have been done to blood vessels as if they 
had started to leak. Now maybe that was because the virus had 
been there and done a hit-and-run and caused that leakage, or 
maybe it was a consequence of an overactive immune system 
response that had done damage to those small blood vessels, but 
that was the finding.
    Now, that is very intriguing. That is not what most people 
would have expected. I got to be careful, though, not to leap 
to the conclusion that the much more common neurological 
consequences that people with long COVID are describing in 
terms of the fatigue, the depression, anxiety. It would also 
have the same findings because obviously what Dr. Nath looked 
at were the most dramatic and most tragic circumstances. And it 
could be that what is going on in the brain in the more common 
circumstances has got a different mechanism. That is one of the 
things we need to find out by studying very large numbers of 
individuals with the most sophisticated kind of imaging that we 
now have at our disposal, and we would aim to do that.
    Ms. Matsui. OK. So I follow along what you are saying. What 
steps are you planning, has NIH taken or planning to take to 
advance research on COVID-19-related neurological symptoms, 
complications, or outcomes?
    Dr. Collins. Well, first, we need to collect as much 
information we can about those presentations, about what the 
symptoms are and carefully record those and make sure we use 
this common data element so we are talking about the same thing 
between different studies, but then I think imaging is going to 
be critical here, and we will invite the participants in this 
metacohort who have neurologic symptoms--some of them; we can't 
afford to probably scan all of them--to look in the most 
sophisticated way to see what has happened in the brain. Is 
there clear evidence of something in the way of a circulatory 
problem? Is there some kind of swelling going on? Is there a 
blood-clotting issue? All that information we just don't have, 
and that is what we need to find.
    Ms. Matsui. All right. Thank you very much, Dr. Collins.
    Dr. Brooks, adverse mental health consequences of COVID-19, 
including anxiety and depression, have been widely predicted 
but are challenging to measure accurately. I am interested in 
the role that electronic health records can play in efficiently 
providing some of the central information needed to understand 
and control the mental health consequences of this pandemic and 
plan for the future ones.
    Dr. Brooks, you mentioned EHRs can be tricky for mining 
accurate race and ethnicity data. Are there similar challenges 
to using electronic health records for monitoring the mental 
health of long COVID-19----
    Dr. Brooks. Sure. There sure are. You know, it requires a 
person enter the data and recognize that there is a mental 
health problem present, but--so many clinicians are trained and 
good at doing that, but as you may have heard, in our business 
in medicine, chance favors the prepared mind. And one of our 
jobs is to get people trained up to recognize when that is 
present and get them to enter it. But there are other ways 
electronic medical records can help us, particularly with 
disorders like these.
    We can look at the prescription drugs they were prescribed, 
drugs they may have been prescribed to treat anxiety, 
depression, pain, fatigue, and that can be another indirect way 
of assessing what is going on. But all of these are, 
unfortunately, still an indirect indicator of what the person's 
illness journey was actually like. And this is where some other 
studies where we follow patients, as Dr. Collins has mentioned, 
really can make a big difference.
    We can do surveys to measure quality of life, social 
functioning, and physical functioning, to actually measure and 
quantify what is going on and then correlate that with the 
imaging, for instance, that he mentioned before.
    Ms. Matsui. OK. Well, thank you very much for your 
testimony, both you and Dr. Collins.
    And, Madam Chair, I yield back. Thank you.
    Ms. Eshoo. The gentlewoman yields back.
    It is a pleasure to recognize one of the doctors on our 
subcommittee, the gentleman from Texas, Dr. Burgess, for your 5 
minutes of questions.
    Mr. Burgess. Well, I thank the chair, and I thank our 
witnesses for being here today.
    Dr. Collins, the observational data that both the vaccine 
will help ease some of the symptoms of long COVID is certainly 
intriguing, but I think you referenced in your testimony and 
certainly we heard on the prehearing chatter across the board 
that perhaps the best offense is a good defense, and preventing 
the illness in the first place may be our best bet for 
preventing patients from getting the symptoms of long COVID.
    So is there an opportunity here for that teachable moment 
where people who are on the fence as far as to whether or not 
they get the vaccine, can we perhaps provide them some 
additional information with, like, what we are doing with this 
hearing today?
    Dr. Collins. Well, Dr. Burgess, it is a great question, and 
let me say I just saw yesterday the effort that the Doctors 
Caucus has made to get the information out there about the 
importance of vaccination.
    Thank you for putting on your white coats and making very 
compelling statements from the perspective of yourselves as 
medical professionals about why this is something everybody 
should take advantage of.
    I do think that the risks of long COVID has not been 
appreciated mostly by the public unless they happen to know 
somebody who has been going through this. I think they have 
particularly not been appreciated by young people who may 
continue to view this as an illness that they don't have to 
worry about too much because they heard that young people 
generally don't have very severe acute illness, although we can 
all say there's plenty of exceptions to that too.
    And so I have started talking about it when I am raising 
the issue about the importance of vaccination. I worry a little 
bit that it sort of feels like, OK, here goes that government 
guy shaking his finger at people again, saying these are all 
bad things that are going to happen to you if you don't get 
that vaccination, which we know is safe and effective.
    So I am trying to moderate that a bit by also saying and 
think of all the things you can do when you get vaccinated, 
like, you know, meet with your friends with your masks off 
inside because you have all been vaccinated and you can hug 
each other again, which is something we have all kind of missed 
for the last year.
    Mr. Burgess. That is a perfect segue to, actually, one of 
the things I wanted to talk about. Look, we are having a joint 
session of Congress tonight. The President for the first time 
is going to be present in the Capitol since his inauguration. I 
won't be there. This is the first joint session of Congress 
that I will have missed in almost 20 years, and the reason I 
won't be there is not because I am boycotting but because we 
were limited to the number of invitations that could go out. 
And, presumably, it has something to do with the continuing, 
lingering effects of the pandemic.
    But here is the deal. We all got vaccinated very early, as 
soon as the emergency use authorization came forward. I can't 
say we all got vaccinated, but a great number of us did. 
Another number of us have already had the coronavirus itself. 
It just seems to me that we are sending the wrong message 
because here we were one of the first groups as a body to avail 
ourselves of the vaccine, yet we are still behaving like we did 
a year ago, like it didn't help us at all. It didn't help us 
get over the effects of the pandemic.
    So I know that it has been correctly pointed out that there 
are others who were responsible for these decisions, but I 
would just ask you in your conversations with House leadership 
to encourage us as much as is practical to get back to normal 
voting patterns, normal hearing patterns, normal visits in the 
office. And because of the protection provided by the vaccine, 
this is something now we can do and perhaps make that message 
more prevalent because there is no question about it, we are 
missing something with getting people--getting to all the 
people who could be vaccinated, and yet some are holding back.
    But I feel like we are sending the wrong message as a body. 
So you referenced the Doctors Caucus. We also sent a letter to 
the Speaker urging the Speaker to get back to a more normal 
activity level in the House because, again, show the power of 
having had the vaccine. So, to the extent that you have the 
availability of making that which is known to the Speaker, I 
would ask that you do so.
    And let me also give a plug for, in Cures, we did the 
interoperability title in the electronic health records. I am 
glad to see that you and Dr. Brooks are using the metacohort 
data and the electronic health record data to a good end.
    Dr. Collins. That is right. It would make a great 
statement, Dr. Burgess--and the Doctors Caucus I know is trying 
to push this--if every single Member of the U.S. Congress, all 
535 would get vaccinated, even those that have had COVID. You 
are better protected to get the vaccine even after you have had 
the natural infection, like President Trump did. That would 
state to the whole country just how crucial this is for our 
future. And I suspect even the Capitol Physician, if everybody 
was fully immunized, would say, ``OK, you guys can get back 
together again.'' I am not going to speak for that physician, 
but I suspect that is the principles that he is looking at 
right now.
    Ms. Eshoo. The gentleman's time has expired.
    I thank the gentleman for raising the points that he made. 
I think the Doctors Caucus needs to meet with the Capitol 
Physician because the lay persons, whether in leadership or 
not, are going with what the determinations are that he has 
made. And I think in both caucuses on each side of the aisle, 
we really need to urge our colleagues--and I said this as we 
were beginning much earlier today--that every Member of 
Congress should be vaccinated, and they are not, and that is 
holding us back. So I just wanted to add that. But I think if 
the doctors meet with the doctor, we might make some better 
headway on this because there is no excuse for 535 not being 
fully vaccinated. You are absolutely right about that.
    So the Chair now has the pleasure of recognizing the 
chairwoman from Florida, Ms. Castor, for your 5 minutes of 
questions.
    Ms. Castor. Well, thank you, Chair Eshoo. This is a very 
important hearing, and I am grateful for your leadership in 
bringing us together. And Dr. Collins, Dr. Brooks, thank you so 
much. Thank you for starting your testimony recognizing this 
very difficult year for all Americans. It is just staggering 
that we have lost over 570,000 Americans and so many more have 
been suffering through with illness or loss. But there is hope 
here. I love the conversation on vaccinations. My office, right 
outside my door here is the health unit, and when I came in 
this morning there was a long line. Remember, yes, it is the 
535 Members of Congress, but it takes all of our professional 
staff, Capitol Police, the custodians, everyone getting 
vaccinated, and I know the Speaker is very eager to get back to 
normal because I have raised this with her, and she has said it 
is time to move that way. So we all have to do our part here 
and back home.
    So thanks [inaudible]. Dr. Collins, when you brought--when 
long COVID kind of entered into the consciousness last year and 
you came with Dr. Fauci and others and said we are going to 
need some long-term studies on the long-term effects of the 
coronavirus, I was--I think that was very timely. Thank you for 
being thoughtful about doing that early on, and I am glad that 
Congress responded in a bipartisan way to get those funds, and 
here we are. You have--you said 273 proposals already. You are 
going to make some decisions next week. I wonder, you know, 
when we first started trying to understand what COVID-19 is, it 
was most analogous for people to the flu, but when you talk 
about flu you don't really think about long-term impacts, 
health impacts to people, but there have to be other infections 
where we have had long-term studies in place, and we have 
learned something about treatments and eventual cures.
    Could you provide maybe some analogies on how important it 
is to have those long-term studies and look at other 
infections, and what we have learned over time?
    Dr. Collins. Sure. Obviously, a particularly dramatic 
historical example of that [inaudible] is HIV/AIDS, where we 
know that somebody infected with that virus can then have 
lifelong consequences, which we can suppress with appropriate 
antiretroviral therapy. So I would love to be where we are with 
HIV for long COVID in terms of understanding the mechanism and 
having a treatment, not that I would want anybody to have HIV 
long term either.
    But we aren't there yet. We don't understand the mechanism 
of what it is that is causing this prolonged set of symptoms 
for long COVID. It is true that there are two other 
coronaviruses that preceded SARS-CoV-2 that got us worried, 
didn't spread in the same way and that being SARS--remember 
SARS back almost 20 years ago, and then MERS in mostly Middle 
East area, and those also were coronaviruses where people were 
acutely very sick and then they seemed to get better, but they 
didn't get all the way better. So there was a prolonged kind of 
potential there of trouble, but there was a sufficiently small 
number of infected individuals in that situation to learn very 
much about it.
    Frankly, I think it is pretty unprecedented for a 
respiratory virus like SARS-CoV-2 to do this. Influenza, yes. 
If you were in the ICU and you almost died and you had terrible 
pneumonia, you would potentially have a long recovery for sure 
just getting over that organ damage, but to have a disease that 
is a respiratory virus where people, many of them, don't end up 
in the hospital but then still 6 months later have serious 
symptoms is kind of unprecedented. So we are kind of in new 
territory.
    Ms. Castor. Dr. Brooks, do you have anything to add?
    Dr. Brooks. Yes. First, I want to echo exactly what Dr. 
Collins said, particularly, the analogy with HIV. Also, that 
the number of people seeking care after recovering from COVID 
is really unprecedented. It is not just people who had severe 
COVID. It may include people who had very mild COVID. In fact, 
we know there is a number of people who never had symptomatic 
COVID who then get these long symptoms. And just historically, 
the other disease I can think of that may have a little analogy 
to this is polio. It was a more devastating sequelae that 
people lived with the rest of their lives, but it was thanks to 
the enrollment of some early cohorts that these patients 
followed over the course of their life that when post-polio 
syndrome later came up in the population, we had the 
wherewithal to begin to understand it. And it happens with that 
condition in many ways sharing some characteristics of this 
post-COVID condition.
    Ms. Castor. Well, thank you both so much for all of your 
work.
    Madam Chair, I yield back.
    Ms. Eshoo. The gentlewoman yields back.
    The Chair is pleased to recognize the gentleman from 
Virginia, wonderful member of our subcommittee, Mr. Griffith, 
for your 5 minutes of questions.
    Mr. Griffith. Thank you very much, Madam Chair. I 
appreciate it.
    And I appreciate the suggestion that maybe the Doc Caucus 
get together with the Attending Physician's Office because, 
while I was one of those who was lagging, I lagged because I 
had--in getting the vaccine--I lagged because I had had the 
disease and felt like others should go first because we do need 
to get our staff and other folks who are here in the Capitol 
vaccinated as well.
    And so I have now had my first shot and will soon have my 
second shot, but also had the disease last year. And so we have 
got to be getting close, of the 435 of us in the House, we got 
to be close to herd immunity if we aren't already there.
    That being said, Dr. Collins, if I could ask you a couple 
questions.
    I have a friend who has long-term COVID. He has been in the 
hospital four times with breathing difficulties and just can't 
seem to shake it. From a public health perspective, does the 
fact that a patient has had COVID-19 change the approach that 
you would recommend to the doctors who are treating or taking 
care of that individual?
    Dr. Collins. That is a great question, and we are learning 
as we go. You may know there are now more than 60 clinics that 
have set up specifically to try to understand how best to 
provide medical care to long COVID sufferers, and you are going 
to hear from two of those clinic leads in the next panel from 
UCSF and from Yale.
    And I think they are trying to see what kinds of things are 
going to be most beneficial. It does seem that some sort of 
pulmonary rehabilitation and cardiac rehabilitation, if the 
symptoms are there, as well as some of the things that are 
being done to help with the brain fog, many of which are built 
upon experiences we have had helping people who had traumatic 
brain injury or concussion.
    Those do seem to help, but at the moment it is really kind 
of learn as you go. So, yes, I would certainly think somebody 
who has got long COVID ought to explain to the physician that 
that was their history because the way in which they are going 
to be understood and managed is going to be very much related 
to that background.
    Mr. Griffith. And even if they go in reporting for the 
first time and maybe haven't been diagnosed with long COVID 
yet, it may be helpful for them to say, ``I had COVID 4 weeks 
ago. You might want to be on the lookout for other issues.''
    Dr. Collins. Absolutely.
    Mr. Griffith. Now, you mentioned the layers of current 
research being done on the effects of long COVID. Is there 
research being done on the relationship between COVID-19 
vaccinations and long COVID?
    Dr. Collins. So we do know that there are reports, and we 
mentioned this a bit earlier, of people who have long COVID 
where the vaccination seems to have provided some relief of 
symptoms, but it is not universal, and it can be pretty mild.
    Otherwise, just flipping it around the other way in terms 
of whether vaccinations prevent you from long COVID, yes, we 
believe so in that they prevent you from getting COVID in the 
first place, 95 percent efficacy for the Pfizer and the Moderna 
vaccine.
    So, as all of us have been saying, if you don't want long 
COVID, then you don't want COVID, then get a vaccination 
because that is the best prevention we have got.
    Mr. Griffith. My friend got the COVID and the long COVID 
before the vaccination was available to him.
    Dr. Collins. Of course.
    Mr. Griffith. Yes. So let me ask this and let me give you a 
chance for a little advertisement. If somebody would like to 
participate in an NIH study, who should they contact or what is 
your website that they should go to?
    Dr. Collins. That is a great question. Thank you for the 
opportunity for the advertisement. It is very easy. You go to 
clinicaltrials.gov--clinicaltrials, one word, dot gov--and I 
looked the last day or so, there are at least 30 clinical 
trials up there right now that are enrolling participants that 
are interested in trying to understand long COVID, and that is 
even before we make this whole bunch of new awards in the next 
3 weeks or so, which is going to greatly expand that. But 
people who want to get started now, clinicaltrials.gov.
    Mr. Griffith. And, of course, you need as many people as 
possible in order to get all the data that you can get?
    Dr. Collins. Absolutely.
    Mr. Griffith. You don't have just 44 people involved in 
long-term study?
    Dr. Collins. No. We want thousands. Tens of thousands.
    Mr. Griffith. Thanks. I just have a minute left.
    Dr. Brooks, vaccines are not currently recommended for 
those who have tested positive for COVID-19 within 90 days. Is 
that based on concerns about the vaccine interacting with the 
virus, or is it an attempt to reserve doses for those without 
antibodies?
    Dr. Brooks. Right. The recommendation is that persons do 
not have to get vaccinated within those 90 days. They could opt 
to wait 90 days, but we do recommend that if people want to get 
vaccinated, they can.
    The concern, though, is that having had the infection, the 
residual immune response to the infection may blunt the benefit 
that you would get from the vaccine. So we want to give time 
that the immune system has basically kind of rested, again, so 
that when you give them that vaccine, they have the best chance 
of having a good response.
    Mr. Griffith. All right. I do appreciate that and encourage 
anybody who wants to be in an NIH study to please do so. And I 
have told the committee several times I am doing--I think I 
might even be in two. But I always go to the same place, and 
they take good care of me.
    With that being said, I yield back.
    Ms. Eshoo. The gentleman yields back, and the entire 
committee thanks you for that public service announcement. 
Really, everyone has a smile on their face. I saw Dr. Brooks, 
thumbs up. So thank you very much for that.
    The Chair is now pleased to recognize the gentleman from 
Maryland, wonderful member of our subcommittee and full 
committee, Mr. Sarbanes, 5 minutes.
    Mr. Sarbanes. Yes. Thank you very much, Madam Chair.
    I want to thank the witnesses for their testimony today.
    Dr. Collins, can you speak a little bit to what the 
intersection is of some of these long-COVID cases in terms of 
the conditions you are starting to see--and obviously there is 
a lot more analysis to be done--the intersection of those kinds 
of conditions with chronic conditions that can impact people's 
ability to work. And I am thinking about the Social Security 
disability categories that result from chronic conditions.
    Do you see an overlap there, and what do you think those 
implications could be in terms of the workplace and employment 
generally?
    Dr. Collins. It is a good question. You know, at the 
beginning, Dr. Brooks outlined this sort of categorization of 
things that are post-COVID syndromes, something we at NIH are 
calling PASC, Post-Acute Sequelae of COVID-19. Long COVID is 
one of them, and that is what we have been talking about 
primarily at this hearing, but there are individuals who suffer 
really significant organ damage during the acute illness as, 
for instance, somebody who had very severe lung disease ended 
up on a ventilator, and that is just going to take a long time 
to get back.
    And then there are people who have the consequences of 
having been extremely ill in the ICU for weeks and the whole 
consequence that has in terms of what you have lost in terms of 
your metabolism and many things.
    So I am setting those in the same context because we need 
to worry about how to manage those individuals as well, and the 
post-ICU syndrome certainly overlaps with people who have been 
in the ICU for other reasons, and we can learn from that. I 
think the one, though, particularly people bring up--and they 
should--is this particular condition called chronic fatigue 
syndrome, or sometimes called MECSF, which was mentioned 
earlier by Dr. Brooks, where these individuals do have profound 
fatigue, oftentimes after an acute illness of uncertain nature, 
which seems like it was probably a virus but generally you 
don't know what it was. And then they just don't recover from 
that and may end up being bedridden for months or even years.
    These are heartbreaking circumstances. We are studying that 
at NIH with a program that has been ongoing to try to figure 
out what the cause is there. I think the overlap here is 
notable in terms of the symptoms, but with the COVID-19 
situation, we have the advantage of actually knowing what the 
infectious agent was. It is SARS-CoV-2, and we are hoping what 
we can learn from that will then map across to things that we 
can do to help people with chronic fatigue syndrome who are 
suffering many of the same consequences. At least that would be 
my hope.
    I feel a great deal of sympathy for people who have 
suffered from chronic fatigue syndrome over many years and 
oftentimes are not being treated by the medical care system the 
way they should be, many times sort of frustrating their 
physicians and the physicians tending not to take their 
complaints seriously. And these folks need our help too.
    Mr. Sarbanes. I appreciate that. I mean, I can see what may 
be coming is that we will be seeing more cases of permanent 
disability coming forward related to long COVID potentially, so 
it will be interesting to begin to build those models in terms 
of what that impact might be.
    Dr. Brooks, I would be curious to hear from you about the 
implications of long COVID when it comes to the workload of 
healthcare providers across the country. We know we have some 
shortages already in certain disciplines in the medical field 
in terms of responding generally to the demand for care out 
there.
    Can you talk about the implications of long COVID against 
that backdrop and particularly how it might affect certain 
specialties and the need to make sure that the pipeline for 
those specialties in the medical field is strong and robust?
    Dr. Brooks. Thank you. That is an excellent question. You 
know, as Dr. Collins alluded, there are 60 clinics roughly, 
maybe more and hopefully continuing to grow, that have stood up 
to begin to address this. And what is characteristic of many of 
these--and I am sure you will hear this later this afternoon--
is there is no post-COVID specialist yet. Maybe there will be, 
but it pulls people from multiple specialties together to 
address the problems we are seeing, predominantly pulmonary 
disease, rheumatology, neurology, neuropsychology. So those are 
areas where we are going to have demand for clinical care with 
these sorts of patients.
    The burden could be large. I mean, consider that today we 
have had almost 33 million infections in this country, and even 
if a very small percentage of them go on to have problems, that 
is a really large burden. So getting ahead of this with proper 
training is important.
    Our agency is--part of our agency's mission is to ensure 
people recognize the condition and know what they can do to 
direct treatment. Ultimately, clinician organizations will pick 
up writing the guidelines in the long term, but in the short 
term we are pulling that together and helping with that 
process. I think----
    Mr. Sarbanes. Thanks very much.
    Dr. Brooks. Yep.
    Mr. Sarbanes. Thank you very much. I appreciate it.
    I yield back.
    Ms. Eshoo. The gentleman yields back.
    And it is a pleasure to recognize the other great American 
on our subcommittee, Mr. Bilirakis, for his 5 minutes of 
questions.
    Mr. Bilirakis. Thank you, Madam Chair. I appreciate it very 
much. Before I get into the questions--actually, Morgan beat me 
to it, but I wanted to volunteer my services as well, clinical 
trial, whatever cohort group because I did--I tested positive 
in early January, and I do have underlying conditions. So, if I 
can be useful, please don't ever hesitate. Please reach out.
    I have a question for the panel before I [inaudible]. How 
long would you say, is there a general consensus as to how long 
a person is immune once they have had COVID-19 prior to the 
vaccine? And I had to wait the 90 days as well because I 
received therapeutics once I was treated. I was treated for 
COVID. And I did have the first vaccine and plan to get the 
second shot next week, and I encourage others to do it as well. 
So, if somebody could respond to my first question, I would 
appreciate it.
    Dr. Collins. Sure. I will do my best, and it is not a 
question that I think we have as rigorous an answer to as I 
wish we did in part because the virus has been evolving. So one 
question is, how long will you be immune to the same virus that 
infected you the first time? And we think that is probably 
quite a few months.
    But then are you immune to a variant of that virus that 
emerges, like the one called B.1.1.7, which now is almost 60 
percent of the isolates we are seeing in the United States 
after it ran through the U.K. and then came to us. That degree 
of immunity will be somewhat lower.
    The good news here, though, is--and this may surprise 
people--the vaccine actually provides you with better broad 
immunity than the natural infection. You don't quite expect 
that to be the case. Usually you would think natural infection 
is going to be the way that revs your immune system to the max 
and the vaccine is like the second best. It is flipped around 
the other way in this case, and I think that is because the 
vaccine really gets your immune system completely awake, 
whereas the natural infection might just be in your nose or 
your respiratory tree and didn't get to the rest of your body.
    With the vaccine, we think the immunity has at least 6 
months, but is it longer than that? We don't know yet because 
this disease hasn't been around long enough to find that out. 
And, so far, the vaccines--the Pfizer, the Moderna--do seem to 
be capable of protecting against the variants that are now 
emerging in the U.S., like this B.1.1.7.
    Mr. Bilirakis. Well, thank you very much. I appreciate it, 
Dr. Collins. That was a great answer.
    Dr. Brooks, can you discuss the study CDC has already set 
up to follow cohorts of patients post-infection? What analysis 
has CDC conducted or recently published using already available 
data? Do these long COVID [inaudible].
    Dr. Brooks. I can't hear.
    Ms. Eshoo. I think Mr. Bilirakis' connection has somehow 
failed.
    Dr. Brooks. Madam Chairwoman, would you like me to try and 
answer, or should I wait?
    Ms. Eshoo. Sure. Go ahead. Can you hear us, Gus? Are you 
back on?
    No, he isn't, but--maybe he can hear. Why don't you take 
his question, please.
    Dr. Brooks. Yes. I would be happy to, and hopefully it is 
recorded so he can get the response if he is not hearing it 
now. So, as I mentioned, we have eight prospective cohort 
studies that are collecting information on people during the 
post-COVID period and also doing electronic health record 
analyses. And actually the data that we have published most 
recently has been the study I think you referred to in your 
opening remarks, the study with Kaiser Permanente Georgia 
published in our MMWR, and this is telling us and is consistent 
with what others are reporting as well that it is a common 
problem after COVID for people to continue to have some 
residual symptoms or complaints that they seek care for.
    They do begin to go down over time for some people, but 
they can persist very long for others. I am sorry I didn't 
catch the rest of his question. If you did, maybe you could 
share it. I would really be happy to try and answer.
    Ms. Eshoo. I didn't. Did Dr. Collins? I don't know. Dr. 
Collins, did you catch----
    Dr. Collins. I am afraid I didn't. I think Congressman 
Bilirakis' link locked at the same moment for all of us.
    Ms. Eshoo. OK. All right. Well, maybe we can when he has 
reconnected, maybe we can circle back with him, and he 
certainly can re-ask the question in the printed questions that 
we--every Member can submit to witnesses. So I believe that the 
gentleman yields back.
    And now, wonderful Member from Vermont, colleague Peter 
Welch, you are recognized for 5 minutes of your questions.
    Mr. Welch. Thank you very much, and thank you very much to 
the witnesses, the extraordinary work that you and your 
institutions are doing. First question is this: With respect to 
the long haul and the necessity to come to some consensus about 
what that is, what the symptoms are, how you differentiate 
between a complaint that is related and a complaint that is 
not? What is the best methodology by which we can come to a 
medical consensus on that, because I would regard that as 
essential to coming to a consensus on how to treat it. I will 
start with you, Dr. Collins, and go to you, Dr. Brooks.
    Dr. Collins. That is a wonderful question, and it is a 
really serious challenge for all of us with such heterogeneity 
in the symptoms that individuals are experiencing. I think with 
a large collection of a very large number of people who are 
suffering these symptoms and enable assists from some machine 
learning efforts to try to identify what is the clustering of 
symptoms that makes the most sense as far as some kind of 
uniform view, that should get us closer than we are right now 
to saying what is the case definition. But I should turn this 
over to Dr. Brooks because CDC's very much engaged in this 
issue of trying to come up with case definitions.
    Mr. Welch. Thank you.
    Dr. Brooks. Thank you. And, Dr. Collins, that is right. A 
lot of it is--this machine learning you pointed out is a new 
tool we have had in the last 10 years or so that is very 
useful. We also pull in information by scanning data sets, 
looking for what people are doing in terms of what visits they 
are making to doctors, to see the specialists they are going 
to, the drugs that are being prescribed. We also interview 
groups of doctors caring for patients to try and get a smell 
test as we are arriving at some definition, does this really 
fit what we are seeing? And we also bounce that off of patients 
and patient advocates, again, to make sure that we are homing 
in on something that comports to what their experience has 
been.
    What really makes this a challenge is the broad 
heterogeneity. And so we have got a lot of work to do. People 
around the world are working on this.
    Mr. Welch. Well, thank you. And the followup on that and 
this whole question of data collection that is so critical to 
diagnosis and then treatment. There is a challenge with our 
BIPOC community and with our lower-income communities that are 
spread throughout the United States of getting this accurate 
data as we need.
    In fact, what you were just describing, Dr. Brooks, is the 
more data, the better. So, if there are certain communities 
that, for a variety of reasons, we don't get the information, 
that compromises your ability to come to conclusions.
    So my question is, first of all, do you agree that there 
has to be additional efforts to get data from communities where 
we don't have all the data that we need, and what can we do to 
allow that to happen?
    Dr. Brooks. I absolutely agree that we have to get these 
data--these are the most affected communities by COVID to begin 
with and therefore where we expect the greatest burden of post-
COVID illness to be. So that is a critical part of what we are 
doing. The methods that we use, a typical one is to over-enroll 
people from these minority communities, whether it be minority 
by race, ethnicity, by income, and other groups.
    We also want to make sure we focus on groups that are often 
affected very heavily by COVID but may not be in the spotlight. 
People who are challenged by housing or justice involved. 
People in incarceration are going to experience this too, and 
they deserve to understand what is going on to be offered the 
best care that is available.
    Mr. Welch. Well, I appreciate you saying that. We all 
deserve it, wherever the person is, but we all need it. We need 
that data in order for you to do their job, and my hope is 
that--and I am sure you are doing this, both the NIH and CDC, 
the lessons learned after analysis, because I think a lot of us 
are now aware that this may not be a one-time event. We have 
got to be prepared for this happening again.
    So thank you very much.
    Madam Chair, I yield back.
    Ms. Eshoo. The gentleman yields back.
    Our subcommittee is really blessed to have physicians, 
doctors, and I want to recognize now the doctor from Indiana, 
Dr. Bucshon, for your 5 minutes of questions.
    Great to see you.
    Mr. Bucshon. Good to see you, Madam Chairwoman, and thank 
you for the time.
    Dr. Brooks, I have a daughter who has had COVID and has 
persistent problems with her smell and not as much her taste. 
Do we know specifically exactly what COVID did to the person's 
neurologic system or whatever to cause that? And based on 
historical problems with that system, the neurologic system, 
the chance for recovery?
    Dr. Brooks. That is an excellent question. In particular, 
because anosmia, or the loss of smell or change in smell, is an 
often overlooked but surprisingly common problem among people.
    Mr. Bucshon. Yes.
    Dr. Brooks. But this disease really seems to target that 
and cause it. I can say this: I have had a particular interest 
in this topic. The reading that I have been doing seems to 
suggest that the virus isn't necessarily targeting the 
olfactory nerves, the nerves that transmit smell, but more of 
the nerves that are sort of around and supporting those nerve 
cells, and it is the swelling and the inflammation around those 
cells that seems to be leading to some kind of neurologic 
injury.
    I will say the good news is that many people will 
eventually recover their sense of smell or taste, but there are 
others in whom this is going to be a permanent change.
    In terms of treatment, smell training--interesting therapy, 
but it really works. And I really want to raise people's 
awareness around that because the earlier you can begin smell 
training, the better the chances that you will recover your 
sense of smell.
    Mr. Bucshon. Yes. She had COVID in late November, and she 
is still having issues with her smell. So I will tell her what 
your recommendations are.
    Dr. Collins, in your testimony, you mentioned that the 
funding the NIH receives from Congress to help examine and 
research long COVID--and I am constantly a supporter of 
enhancing your funding, by the way, and remain committed to 
doing so, especially for research like this. I realize this may 
be a little bit premature based on what we have been talking 
about, but what percentage of the NIH funding is going to be 
directed towards potential therapies for long COVID in the 
coming months?
    Dr. Collins. It is not premature at all, Dr. Bucshon, and I 
appreciate your asking it. And I think patients who are 
listening to this hearing probably are really interested in 
knowing what is this metacohort all about, and is it basically 
just collecting information? Are you all about trying to find 
answers?
    We are all about trying to find answers. So we would aim to 
initiate therapeutic interventions as soon as we have this 
cohort together and begin to imagine what might potentially 
work.
    In a way, you could say we have already started that in one 
instance because we are running a lot of clinical trials on 
acute COVID, and at least one instance, we have now enrolled 
participants who are over their acute phase in anticoagulants 
because we think maybe the ongoing hypercoagulable state where 
you have small blood clots affecting various organs may be part 
of long COVID. So that one is already underway, but there will 
be other opportunities to do this. We will have to think about 
what exactly would be the safe kind of interventions that have 
a decent chance of success, and we would design those as 
randomized trials so we will really know if they worked or not.
    But I want to say, yes, very much to everybody who is 
listening: This is not just admiring the problem. This is 
actually getting the data we need to initiate the interventions 
that we hope will help.
    Mr. Bucshon. Yes. And I want to make sure that we provide 
you the resources to do that. And you mentioned, I think, 
anticoagulants. Do you have any other possible treatments that 
you are already looking at other than the anticoagulants for 
long COVID?
    Dr. Collins. Well, certainly, people are contemplating 
whether this would be an instance where steroids or other 
immune suppressants might be helpful because there is some 
possibility here that this is an autoimmune condition, and we 
know in other autoimmune conditions, that can help, or even 
such things as giving intravenous immunoglobulin, which we know 
can also sometimes help in an autoimmune situation.
    All the things that are currently on that list are chosen 
because they are known to be relatively safe. I don't think we 
are ready to start giving toxic substances until we know things 
a little better.
    Frankly, you are an experienced physician. It is always 
easier to know what to treat the patient with when you 
understand their condition.
    Mr. Bucshon. Yes.
    Dr. Collins. And here we are. We don't know whether long 
COVID is because there is a persistence of the actual virus in 
the system, in which case maybe that is why immunization is 
working, or maybe it is an autoimmune response, or maybe it is 
a consequence of blood clotting that has left damage in various 
organs, or maybe it is something we haven't thought of yet. And 
the most critical thing is to get all of that clinical data, 
develop those biomarkers, and then we will be able to target 
the therapy in a more rational well.
    Mr. Bucshon. Well, thank you for that, Dr. Collins and Dr. 
Brooks. I appreciate that.
    And, Madam Chairwoman, I yield back.
    Ms. Eshoo. The gentleman yields back.
    Important questions and observations in that exchange.
    With the permission of Members, I want to circle back with 
Mr. Bilirakis and allow him 1 minute to ask the question that 
none of us heard. We are dying to hear it.
    You need to unmute, Gus.
    Mr. Bilirakis. Here we go.
    Ms. Eshoo. There you are. OK. You have a minute.
    Mr. Bilirakis. I am so sorry. OK. I have a minute, so I 
will be quick.
    Dr. Brooks, can you discuss the study CDC has already set 
up to follow cohorts of patients post-infection, what analysis 
has CDC conducted or recently published using already available 
[inaudible]? Do these long-COVID symptoms eventually resolve, 
and is there any data, anecdotal or otherwise, that suggests 
this COVID vaccine may help reduce symptoms for long-haulers?
    Now, I know you covered this, but you may want to elaborate 
a little bit on this.
    Dr. Brooks. Pardon me. I am going to try to do it in a 
minute or less. So we have large cohort studies. They are 
underway. We have published data most recently that the 
chairwoman mentioned during her opening from the Morbidity 
Mortality Report in collaboration with Kaiser Permanente 
Georgia showed that there was remarkable incidence of people 
seeking care after recovery, unheard of with most illnesses of 
this kind like flu.
    So that is a warning sign. We also were using electronic 
health data combined with cohort studies to look at all of 
these kinds of questions. We have a number of publications in 
the pipeline that you should be seeing shortly in journals, as 
well as the MMWR. And I will also point out there is some 
excellent studies--we are not--we don't hold all the 
information. They are fantastic studies also by some of our 
colleagues out there, in particular, one from a group in St. 
Louis at the Veterans Administration Hospital, a place that I 
have worked for many years and love.
    Lastly, to your question about does vaccine help with long 
COVID: It has been mentioned a couple of times there are these 
well-reported anecdotal instances and even some early research 
data that suggests they may, but we really need more robust 
data to say that with a surety and to know how to use 
vaccination, if we can, to ameliorate the post-COVID 
conditions.
    Mr. Bilirakis. Thank you very much.
    And I want to yield back, but I want--Dr. Collins, my dad, 
Congressman Bilirakis, says hello. Take care.
    Dr. Collins. Thank you. Please tell him hello back.
    Ms. Eshoo. And the gentleman yields back.
    We all remember and have great affection and respect for 
your father, who was the chairman of this subcommittee during 
his service in the Congress.
    The Chair now is pleased to recognize the gentleman from 
Oregon, Mr. Schrader, for your 5 minutes of questions.
    Mr. Schrader. Thank you very much, Madam Chairwoman. Good 
hearing today. Very interesting. Learning a lot.
    Dr. Collins, given the fact that the symptoms of long COVID 
mimic the symptoms of a lot of other diseases, I guess a very 
basic question is, how are we just ruling out these other 
diseases coincidentally showing up in these patients?
    Dr. Collins. Another great question. The easiest way to be 
sure in a given individual that this is a consequence of the 
COVID infection is to have absolutely clear definition that 
they had the acute illness with the positive viral test. If 
that is not available, then an antibody test to show that they 
previously had it.
    Having said that, going back a year where tests were not so 
readily available and the antibodies may have waned by now, we 
have a lot of people, and you will hear in the second panel 
what this has been like for folks who have the symptoms of long 
COVID but don't have this clear laboratory evidence of having 
had the acute infection. And we need to take care of those 
folks as well.
    But more recently now that I think we have widespread 
testing that is available, and we talked about RADx a bit 
earlier, which has contributed to that, I think we are in a 
circumstance to be able to have that part of the diagnosis.
    But I think maybe your question is also suggesting maybe 
there are people who had acute COVID infection and now they are 
having something else that isn't really related to that but was 
going to happen anyway. Somebody who has the onset of a new 
illness like rheumatoid arthritis, and so they are having a lot 
of joint pains. You might assume, therefore, oh, this must be 
long COVID, but it might be something else. So the people who 
are running the clinics, and you will hear from two of them in 
the next panel, have to watch closely that we don't end up 
merging together conditions that don't belong there and maybe 
things that really aren't long COVID but deserve a different 
kind of treatment need to be recognized and appropriately 
managed.
    Mr. Schrader. On one of those diseases, I have got, 
unfortunately, some constituents who suffer from chronic 
fatigue syndrome, ME, and, you know, very concerned, you know, 
about that and wondered, you know, that is an entity, as I 
understand it, unto itself, but one of the main symptoms that 
folks with long COVID talk about is this chronic fatigue. And 
as I understand it, with some of the studies on chronic 
fatigue, they think it might be virally induced. Could it be 
that other viruses, other things have caused this, and are 
there studies going on right now with long COVID causing or 
increasing the frequency of chronic fatigue syndrome?
    Dr. Collins. There is certainly a lot of overlap in the 
symptoms, and I think we need to learn from that. People with 
chronic fatigue syndrome many times report an acute illness 
that sounded like it was a viral infection of some sort, a 
fever, maybe being in bed for a day or two, but then they don't 
get better. And that has a lot of overlaps now with what we are 
seeing with long COVID.
    With chronic fatigue, though, we almost never actually 
catch the original infection in the act, so we don't know what 
it was, but it could be that this is a pathway that other 
infections can also induce occasionally in individuals. My hope 
would be that, as we study long COVID and look at those 
comparisons with chronic fatigue syndrome, we will learn a lot 
about both of them. We will figure out how they are similar, 
how they are different, and how, if we can identify 
interventions, they might work for both of those groups because 
there is lots and lots of people with chronic fatigue syndrome 
who are still waiting for something that is going to help them.
    Mr. Schrader. Right. Right. Yes. Might be some overlap. I 
guess, lastly, my team and I have been reading a little bit 
about high levels of cytokine secretions that occur sometimes 
in relationship to the disease and wonder if that is a 
biomarker for long COVID potentially, and are you looking at 
other biomarkers to, again, help us get a handle on cause and 
effect?
    Dr. Collins. Well, you are right on the place we need to 
go, and certainly we see cytokine elevations, even cytokine 
storms in people with acute illness, particularly those that 
are very sick in the hospital, but it hasn't been so obvious in 
people months later who are still suffering from long COVID. 
There is a very interesting paper just came out about a few 
days ago in the journal called Nature where they studied 73,000 
veterans and followed them 6 months after they had an acute 
COVID infection and looked to see were there any kind of 
markers there. There is nothing that jumps out at you, like, 
oh, wow, that is it, but there are laboratory abnormalities 
that do seem to occur more frequently in people with long COVID 
than in the people who didn't end up with that consequence.
    So that is kind of a start. We want to take that kind of a 
study and expand it even more rigorously to more and more 
groups, but that was a really important one.
    Mr. Schrader. Very good. Very good. Well, thank you, Dr. 
Collins, for all your work and thank goodness we have NIH, and 
you are doing wonderful things and look for more great things 
in the future.
    And I yield back, Madam Chair.
    Dr. Collins. Thank you.
    Ms. Eshoo. The gentleman yields back.
    The Chair is very pleased to recognize another one of our 
doctors, Dr. Neal Dunn from Florida.
    And he will be followed by Congressman Cardenas from 
California. So I think I will announce that so Members will 
know who's next in the lineup.
    So you are recognized for 5 minutes for your questions.
    Mr. Dunn. Thank you very much, Madam Chair. I am pleased 
the committee is holding this hearing today about the long-term 
health complications that can follow COVID-19 infections. I had 
the opportunity to meet with a group of COVID long-haulers from 
Florida last week, and hearing from these patients confirmed my 
impression about the mysterious and lingering medical 
conditions that affect a number of COVID survivors, even long 
after the infection has past.
    The group I spoke with had teamed with an advocacy group 
for myalgic encephalitis and chronic fatigue syndrome as my 
colleague, Representative Schrader, just mentioned, diseases 
that also affect and debilitate multiple body systems often 
following a viral infection. And their hope was, of course, 
that existing research on MECSF can shed some light on why 
COVID patients are facing an array of symptoms that are often 
similar.
    So I commend our witnesses and our researchers from other 
academic institutions for their rapid response to this problem. 
One question they had that really stuck with me from that 
conversation with one of my long-haul constituent patients was, 
how do I get my doctor to believe me? And this came from a 
constituent who had--a doctor--who had some, quite frankly, 
perplexing symptoms and had never tested positive. So--and this 
was just mentioned also. To that problem determining who has, 
indeed, been infected with SARS-CoV-2, don't you think we need 
to immediately scale up our ability to test for patients for 
humoral immunity to COVID, not just antibodies but testing for 
T cell immunity, which we know is a much more reliable test for 
prior infections no matter how far in the remote past?
    Dr. Collins, I am unaware of a shark tank actually 
addressing that problem.
    Dr. Collins. This would be a great shark tank opportunity 
for sure. Dr. Dunn, you ask a great question. One of my other 
jobs in COVID is cochairing the effort between industry and NIH 
and CDC and FDA on everything we are doing about COVID 
therapeutic trials.
    We had a big discussion just this morning about T cell 
testing and why we are not doing more of that in terms of the 
ability to assess response to vaccines as well as to natural 
infection. And there was, shall we say, a vigorous disagreement 
amongst the experts about exactly how to do it. And that was 
the problem. People hadn't quite arrived at a consensus about 
what is a reliable way to assess T cell response, whereas 
measuring antibodies, everybody kind of agrees how you do that.
    Mr. Dunn. Well, we have the tests, though, that we use for 
T cell immunity, and I have read papers on how to scale it up. 
So I am hoping--you know, nobody is better qualified to scale 
this up than you. So I am not going to charge you with this, I 
guess, the responsibility, but I would encourage you to look 
into it vigorously.
    And by the way, I want to be the first to say that I don't 
think every single primary care physician or urologist, like 
myself, to be up to date on the latest research of long COVID, 
but I do hope that we are empowering all the physicians with 
the information they need to best serve their long-haul 
patients or direct those patients to the proper specialists.
    So, you know, to that question, I would ask both Dr. Brooks 
and Dr. Collins, what educational resources can you direct 
physicians like me for patients who present with these curious 
long-term symptoms following COVID? And have we developed a 
sense of recommendation regarding which specialists are best 
equipped to assist these patients?
    Dr. Brooks. I am happy to answer that question. I mean, 
this is something we have been working on since--very early 
when we recognized long COVID. We hold regular webinars and 
calls for clinicians they can call into. These are often 
attended by thousands of providers. We use these as an 
opportunity to raise awareness. Because I think you made a 
really critical point that patients feel like their doctors 
don't recognize their problem or they don't accept that it is 
possible they have this condition.
    We use those calls in webinars to raise awareness that this 
is a real entity. We also then publish papers and put out 
guidelines that illustrate how to diagnose and begin to pull 
together what we know about management.
    We have completed a first draft of interim guidelines that 
are in the clearance process, we call it, here at CDC. They 
should be coming out very shortly. They were drafted in 
collaboration with multiple physicians groups, also passed by a 
number of advocates with the patient population. And we will 
continue to do that. They will be updated regularly.
    They emphasize a couple of points to what you said, 
particularly the multidisciplinary nature of what you need to 
do to manage these folks and how important it is to recognize 
that you may have this disorder and direct them to care----
    Mr. Dunn. Dr. Brooks, we are going to get cut off here in 
just a second. But if you could just either put me on a list 
that gets that information.
    Dr. Brooks. You bet.
    Mr. Dunn. I am easy to find. Or you can tell us right now 
and I will write it down.
    Dr. Brooks. Sure.
    Mr. Dunn. Where do I go?
    Dr. Brooks. You go to cdc.gov and look for COCA calls. 
Those are Clinician Outreach and Community ... something. I 
am--a bad acronym, I am very sorry. Community something. I will 
get it to you.
    Mr. Dunn. All right.
    Dr. Brooks. Look for our guidelines. They will be 
advertised heavily to clinicians because we want to ensure 
people like yourself get them.
    Mr. Dunn. Thank you so very much.
    Thank you, Madam Chair. Thank you for your indulgence. I 
yield back.
    Ms. Eshoo. Thank you, Doctor. It is great to get that 
information out, because our constituents need to know if their 
doctors know. So it is really elemental.
    It is a pleasure to recognize our patient colleague from 
California, Mr. Cardenas, for his 5 minutes of questions.
    Mr. Cardenas. Thank you very much. I am glad we got that 
glitch out this morning so we could continue this amazing 
hearing.
    Ms. Eshoo. Yes.
    Mr. Cardenas. And I just wanted to take the opportunity to 
thank Dr. Brooks and Dr. Collins for committing themselves to 
public service. This is critical that we are able to pursue 
what you are doing and your respective duties because it truly, 
truly, truly is lifesaving en masse, actually. So thank you so 
much for making yourself available for this hearing.
    And I just want to remind the public that this really is 
what Congress is about. You have people from all over the 
country, from all walks of life, learning from these two 
experts and then from the next panel so that we can make 
decisions and we can actually legislate for the people of this 
country. And fortunately enough, we are the leaders in the 
world when we do it right. So I just wanted to thank the public 
for tuning in to this important discussion.
    Social determinants of health are the conditions in the 
environments where people are born, live, learn, work, play, 
and worship, and have a major impact on people's health, well-
being, and quality of life. Examples of social determinants of 
health include things like access to nutritious foods and green 
space, clean air and water, safe housing, and transportation 
options.
    Dr. Collins and Dr. Brooks, could you discuss the 
relationship between social determinants of health and COVID-
19, as well as on long COVID? And what are some of the ways we 
can respond to these things?
    Dr. Collins. Well, that is a profoundly important question. 
Certainly, we have seen it is unmistakable that social 
determinants have played a major role in who is most likely to 
have been affected by this terrible pandemic. This has hit 
particularly hard in those same communities that already 
suffered from health disparities: African Americans, Latinos, 
Native Americans. And that is not because they have some 
different genetics. Even though I am the geneticist, let me say 
I don't think that has anything to do with it. It has to do 
with their access to care, with their ability to be able, if 
faced with a pandemic of this sort, to isolate at home, like I 
have been doing for the last year, or whether they have to be 
out there going to work in order to put food on the table.
    So if you needed any more evidence that our healthcare 
system does not give equal treatment to everybody, look at 
COVID-19, because the consequences are quite obvious. And a lot 
of that is the social determinants and the way in which our 
society does not provide those kinds of opportunities for 
health equitably to everybody. And that will play out and 
already is in terms of long COVID, because the gateway to long 
COVID--a terrible gateway that it is--is getting COVID in the 
first place and knowing, therefore, that these underserved 
communities have been hit twice as hard or, in some cases, 
three times as hard with the original infection. You know that 
is going to also play out in terms of what happens next.
    And we also know that people with long COVID who come from 
underserved populations are less likely to get the kind of 
medical care that they now are looking for, just because of the 
way our system is set up. So there is all kinds of aspects 
about this that is shining a bright light upon the way in which 
our system in this country needs a lot of work. If we are going 
to take what we have learned about social determinants in 
health and the inequities that are attached to various other 
aspects of our society and try to implement those in a way that 
would be more equitable and just and fair--and that is a long, 
hard problem that we have lived with for far too long, but I 
hope this is one of those moments where we can look at it 
collectively and try to see what we can do about it.
    Mr. Cardenas. Thank you.
    Dr. Brooks. I would just like to add that this COVID-19--
this pandemic has been unprecedented in terms of really 
revealing long-standing social inequities, sometimes even 
embodied in what we call structural racism that are driving the 
disparities that we are now measuring. It is not pleasant to 
watch these numbers coming in and see how this is playing out.
    However, as Dr. Collins noted, this is also an opportunity 
to start making changes that will help rectify some of those 
inequalities. And we do it not only by addressing differences 
by race and ethnicity, but also imbalance in terms of rural or 
urban or by educational attainment or by income inequity.
    I think a critical thing to do first, though, is to listen 
to these communities. We have learned in our agency that before 
you go offer help to somebody, find out what they want so that 
you could learn what is the help that they need and it is going 
to resonate with them. And we spend a lot of time doing that as 
we introduce studies into communities, understanding sort of 
how that might play out, how we can help address the problems 
that they are facing.
    Mr. Cardenas. Thank you. And with the few seconds I have 
left, I just want to encourage, of the 27 institutes and 
centers within the National Institutes of Health is the 
National Center for Complementary and Integrative Health. I am 
hoping that they are as involved as any other portion of your 
research to make sure that we get those answers and the 
solutions we need for all of our constituents.
    With that, I yield back.
    Dr. Brooks. And they are.
    Ms. Eshoo. Unmute. The gentleman yields back.
    It is a pleasure to recognize the gentleman from Utah, Mr. 
Curtis, for your 5 minutes of questions.
    You need to unmute. Can't hear you.
    There you are.
    Mr. Curtis. [Inaudible.]
    Ms. Eshoo. Mr. Curtis, there is something wrong with the 
transmission and----
    Mr. Curtis. Is that better?
    Ms. Eshoo. Oh, that is much better.
    Mr. Curtis. All right. I was using a remote mike and I just 
unplugged it. Thank you. Thank you for your patience.
    Ms. Eshoo. Now we can hear you loud and clear. You may 
proceed.
    Mr. Curtis. Thank you very much.
    I wanted to join my colleagues in their appreciation for 
our witnesses and for this hearing.
    And let me start with you, Dr. Collins. I believe that NIH 
recently started granting resources to research institutions 
like Harvard to study long-COVID patients. And I am curious if 
you are seeing trends among the patient population that you are 
studying that you have observed. For example, do patients with 
underlying health conditions, are they more likely to have long 
COVID? I am curious what you are seeing there.
    Dr. Collins. Well, yes. When one looks at the resurgence 
already going on, there is a lot happening, not quite yet on 
the scale that we think we are going to need to really 
understand this with a level of intensity that it deserves. But 
it certainly does seem that the risk of developing long COVID 
goes up.
    It is fairly clear that the initial seriousness of the 
initial illness is somewhat of a predictor. Certainly, people 
who are in the hospital have a higher likelihood of long COVID 
than people who stayed out of the hospital. But people who 
weren't hospitalized can still get it. It is just at a somewhat 
lower rate. It is even possible, if you look at the symptoms 
that somebody suffers in their first 7 days of the acute 
illness, to do a pretty good prediction now about whether they 
are likely to end up with long COVID. That is a paper that has 
just recently come out that looks fairly compelling but needs 
to be replicated.
    The risk factors: older-age people, higher likelihood. 
Women have a slightly higher chance of developing long COVID 
than men. BMI, obesity also seems to be a risk for the 
likelihood of long COVID. Beyond that, we are not seeing a 
whole lot of things that are predictive. And there must be 
things we don't know about yet that would give you a chance to 
understand who is most vulnerable to not be able to just get 
this virus out of there and be completely better. But we don't 
know the answers just yet.
    Mr. Curtis. I think we are all looking forward to answers.
    Let me build off of that question and also refer back to 
something a couple of my colleagues have asked about. And Dr. 
Dunn was very good about asking this from a physician's 
perspective.
    I would like you to put a patient's hat on for just a 
minute and go back to the same theme of, like, how do we know? 
And hypothetically, during this last year, every time I get a 
runny nose, a cough, or a headache, I would run down to be 
tested, thinking, oh, my goodness, I have COVID. And, for 
instance, a seasonal allergy could give me a headache or 
drowsiness. From a patient's perspective, how do they know to 
seek out treatment? And, two, where do they go for that 
treatment?
    We have heard today that can be very confusing, from a 
doctor's perspective, even more so imagine from the patient's 
perspective. So what advice to those people listening to this 
hearing today who think that they may have some long-term 
symptoms do you have?
    Dr. Collins. Dr. Brooks, I think CDC is right in the middle 
of that.
    Dr. Brooks. Yes. Thank you. That is an excellent question. 
And I would advise patients a couple of different ways. First 
of all, if you are having symptoms that you haven't had before, 
something new following your COVID--chest pain, difficulty 
breathing, you can't get your thinking clear, you are just not 
getting better the way that you thought you should--have a low 
threshold to seek care. Your primary care physician can help 
determine if it is something else that is causing those 
symptoms, or maybe it is long COVID. But one of the first steps 
is to make sure it isn't something else that we can treat and 
take care of.
    Also, documenting that there was a COVID infection can be 
very helpful. However, as Dr. Collins pointed out, we have an 
awful lot of people who never had the opportunity to be 
diagnosed but developed these symptoms, so we don't have that 
clue.
    And then lastly, the temporal association, that is the 
timing of what happened. You felt sick with a disease that 
looked a lot like COVID, and then weeks or months later you are 
still having this cough, your fatigue is just getting worse, I 
can't think clearly, and my sense of smell is not coming back 
the way that it was supposed to. That should bring people to 
medical care.
    I hope that--you know, sometimes we worry a lot about 
driving people to care who were worried but really generally 
doing OK. But in this case, while we are learning more about 
this, that may be all right for the short term until we really 
can discriminate more clearly what defines this. We are in that 
stage of learning.
    Mr. Curtis. And just with a couple seconds left, where do 
they go? Do they go to their primary care physician? Do they 
need to go to a specialist? Where would you send them?
    Dr. Brooks. I would urge they start first with a primary 
care clinician. And if they are concerned about potentially 
having post-COVID, they could try to seek out a post-COVID 
clinic in their area, if there is one there. They tend to be 
right now affiliated with academic centers and hospitals that 
tend to be in large cities. That may not be available to 
everyone. But one of our duties, our mission at CDC is to raise 
awareness among frontline providers to recognize this syndrome.
    Mr. Curtis. I am sorry to cut you off.
    Madam Chair, thank you for the few extra seconds. I yield 
my time.
    Ms. Eshoo. Absolutely, Mr. Curtis. And we restored the 30 
seconds that were lost because of a bad mike. So thank you.
    And the gentleman yields back.
    A pleasure to recognize another one of our physicians on 
the subcommittee, Dr. Ruiz, of California. You are recognized 
for 5 minutes.
    Mr. Ruiz. Thank you, Chair. And thanks to both of our 
witnesses today.
    We have clearly not even scratched the surface of what 
there is to learn about long COVID, how it affects individuals 
physically, mentally, and even economically. And as a doctor, I 
am very concerned about the initial research that I have seen.
    As someone who grew up and then practiced medicine in a 
farmworker community with low health access, I am worried as we 
learn more that our historically underserved communities will 
once again be left behind, just as they were with testing and 
now with vaccination rates. I applaud the actions the Biden 
administration has taken to address these issues. And moving 
forward, we must be vigilant to make sure our underserved 
populations do not get left behind as we study, identify, and 
treat long COVID.
    Dr. Brooks, I was pleased that your testimony made multiple 
references to equity and disparities. It is clear that you 
recognize the importance of the issues and that it will be at 
the forefront of your work. In your testimony, you acknowledged 
that there are barriers to accessing post-acute COVID care 
clinics such as transportation or insurance coverage. What is 
the CDC going to do, and what can Congress do, to address these 
barriers and increase access for all populations to get the 
post-acute care that they need?
    Dr. Brooks. Thank you, Congressman, for that question. It 
is really a critical one, because you have pointed out some of 
the important disproportionalities that have been occurring in 
this country around COVID. And in some ways they are baked in a 
bit, and we want to fix that.
    One of the first things we are doing is we have put about 
$3 million, if I am not--$3 billion, rather, into building 
vaccine confidence, focusing on underserved communities in 
particular.
    In addition, we have created $2.2 billion worth of funding 
opportunities for people to help address these disparities and 
bring the care and the knowledge necessary to the communities 
like the one you were describing so they can get the access 
that they need.
    And then I think a really important aspect that I 
particularly like is building this core of community health 
workers. We have invested about $300 million into community 
health workers who ideally are from the communities that are 
infected and can be trusted messengers with that constituency.
    Mr. Ruiz. I am a big fan of the community health worker 
model ever since my medical school days with Partners in Health 
program. And in the Hispanic communities they are called 
promotoras, and they have been integral in doing the outreach 
to the hardest hit, hardest to reach communities in my district 
and throughout our Nation.
    I am just concerned because disproportionately Hispanics, 
African Americans, Native Americans have been infected at a 
higher rate, dying at a higher rate. They will have the long 
COVID at a higher rate. And we need to make sure that as we 
build a system of post-acute care for long COVID, that we don't 
use traditional systems of just tertiary care, affluent 
hospitals being the locations of these treatment centers. We 
need to make sure that we take them down into the communities.
    So you also in your testimony talked about efforts to raise 
awareness of post-COVID conditions among patients and 
providers. What efforts are being made to target the 
underserved communities?
    Dr. Brooks. Right. That is an excellent question. So we 
work very closely with a number of types of groups of people to 
try and bring these messages that we are sharing with 
clinicians right now also to providers that are not just--
necessarily have all the access in the world to the internet, 
like we hope everybody has, but also some people who may not 
have that kind of access. We work with community-based 
organizations, community health workforces that may be in the 
field, our allied partners and pharmacies. And then we also tap 
into the wealth of the colleagues that we have, who have 
specialized knowledge and relationships with these communities, 
like the Hispanic Medical Association and the National Medical 
Association, as well as other national organizations that are 
empowered as being trusted messengers, like the Urban League.
    You know, this is an area that we are going to be hopefully 
paying a lot of attention to as we begin to develop more----
    Mr. Ruiz. Well, I can assure you that the Congressional 
Hispanic Caucus will be paying a lot of attention----
    Dr. Brooks. Good.
    Mr. Ruiz [continuing]. And will be insuring that you all 
pay close attention to these issues, because equity needs to be 
part of the design, not an afterthought of policy.
    Let me ask you another question while I have you and Dr. 
Collins here. Multisystem inflammatory syndrome in children has 
disproportionately affected African Americans and Hispanic and 
Native American kids. Up to three out of four children who 
suffer from this illness are minorities. One, have we found 
long--what is the rate of long COVID in these children? And, 
two, what is NIH and CDC doing to address multisystem 
inflammatory syndrome in children?
    Dr. Brooks. Well, I will use the acronym MIS-C, 
multiinflammatory syndrome in children. The good news here is 
that when recognized early, almost every child does well and 
gets better. To the best of my knowledge, we really haven't 
seen a lot of long COVID, if you will, the way we are 
describing it in these children. Early recognition is key here.
    We have also developed case definitions, provider 
information, aiming at providers who treat populations of 
children who come from racial and minority communities to raise 
the flags when they get early recognition of these, of the 
possibility of this condition.
    I just want to also add that we see this in adults. And the 
demography is similar that it tends to be in the populations 
most heavily affected by COVID, those that are racial or ethnic 
minority or underresourced, and we are trying to raise 
awareness in the same fashion among those communities.
    Mr. Ruiz. Thank you. My time is up.
    Ms. Eshoo. The gentleman yields back.
    The Chair now has the pleasure of recognizing another one 
of our important doctors on our subcommittee, Dr. Joyce of 
Pennsylvania. And he will be followed by Congresswoman Debbie 
Dingell of Michigan.
    So you are now recognized for 5 minutes, Doctor, for your 
questions.
    Mr. Joyce. Thank you, Chair Eshoo and Ranking Member 
Guthrie, for holding this important hearing.
    As we listen to the approach that we need to be taking for 
post-COVID condition, it brings to mind another medical 
situation which many of us will recognize: Acute strep throat, 
strep pharyngitis, when treated early, diagnosed, prescribed 
penicillin, has a rapid recovery with very little sequela. But 
if undiagnosed or untreated with penicillin, can go on to 
develop rheumatic fever, a disorder which can affect the heart, 
the brain, the joints, and the skin. Early diagnosis and 
treatment is the key, but having that treatment is so 
essential.
    As we look to prevent COVID conditions, the post-COVID 
conditions that we are discussing here today, how important is 
it that, A, we look at those who have had treatment with 
monoclonal antibodies to see whether or not they have gone on 
to develop post-COVID syndrome? And do you see a role in 
continuing to develop the necessary therapeutics so that we can 
prevent post-COVID conditions?
    And, Dr. Collins, I will ask you to address this first.
    Dr. Collins. And that is just a great set of questions, and 
very much on my mind. Yes. As part of this metacohort that we 
are putting together to try to understand the causes and the 
ability to prevent long COVID, we are enrolling those who have 
taken part in our therapeutic trials, and many of those are on 
monoclonal antibodies. We want to find out whether monoclonal 
antibody treatment reduced the likelihood of that individual 
going on to long COVID.
    But monoclonal antibodies are not universally successful. 
People still can develop symptoms from that, but we hope that 
if this is actually going to provide some benefit, we could see 
that.
    But your point about the need ongoing for treatments and 
particularly for oral agents that could be given to anybody as 
soon as they get a positive viral test is very much front and 
center of everything that we at NIH are trying to do right now 
in collaboration with our pharmaceutical partners. In a 
partnership called ACTIV, which stands for Accelerating COVID-
19 Therapeutic Interventions and Vaccines, we are running a 
total of six master protocols right now on therapeutic agents 
that we hope will have this benefit.
    It has been frustrating. Most of the things we all had 
hoped for didn't turn out to work, but there is plenty more in 
the pipeline, including now some very more sophisticated 
designer drugs that really interfere with the viral lifecycle, 
which is what we most would like to have. So we are going to 
push very hard on that, because as much as we think we would 
like to drive this virus away with vaccination--and we will do 
a pretty good job of that in this country--it will still be in 
the world, and it will still be popping up in hotspots in our 
country as well. We need to have effective therapies that keep 
people out of the hospital and maybe keep them out of long 
COVID downstream. It is a great point.
    Mr. Joyce. Dr. Brooks, would you address this as well?
    Dr. Brooks. Sure. I want to say first, the epidemiology 
also gives us a clue here, which is that a paper that we both 
referred to previously showed very nicely that the more severe, 
the more significant the illness the person had, the greater 
likelihood it was that they were going to develop long COVID. 
What that means is, not only preventing long COVID--excuse me, 
preventing COVID infection in the first place, but treating it 
early to ameliorate the severity of that infection, if 
diagnosed, really makes a difference. This is a place where 
these drugs like the monoclonal antibodies have some 
opportunity, and we hope that there will be other therapies 
coming along soon.
    Another area of research would be looking for preexposure 
prophylaxis or some kind of medication you could take if you 
are in a jurisdiction where the virus was circulating or had 
known you had been exposed to it that you might be able to use 
to prevent developing the infection if you were exposed. A 
nasal spray, a single pill, all of these are things that are 
out there being looked at.
    So I really think whatever we can do to not only prevent 
infection but treat it as early as possible and continue to 
develop excellent therapeutics that lessen the severity of the 
disease or prevent it from happening are going to be the way to 
impact these--the number of people who develop long COVID.
    Mr. Joyce. And, Dr. Brooks, I think it is so important that 
you bring that into the discussion, that we need to have that 
nasal spray. We need to have that ability to take an oral 
medication. This is going to be the multipronged approach, our 
pathway through this pandemic.
    In the few seconds I have remaining, Dr. Collins, could you 
please comment on--you said 273 proposals that you are looking 
at at the NIH. Do any of those include HLA and preexisting 
parameters that an individual might have that would predispose 
them to post-COVID condition?
    Dr. Collins. Another great question. Those most definitely 
will be included in this metacohort. The applicants are coming 
forward with particular cohorts that they already are offering 
up as a means of figuring out how we can get as many possible 
people involved in this study as possible. And then there is 
this clinical sciences core, which is going to look at all of 
the cohorts and say ``What lab tests should we do?'' And I 
can't imagine that HLA won't be one of them, because of what we 
know about how that plays a role in so many autoimmune 
diseases.
    Mr. Joyce. Again, my time has expired. But, Madam Chair, 
this has been an important meeting. Thank you and Ranking 
Member Guthrie for arranging this.
    Ms. Eshoo. The gentleman yields back. And I appreciate 
those comments, and we appreciate you.
    The Chair now recognizes the gentlewoman from Michigan, 
Representative Dingell, for her 5 minutes of questions.
    Mrs. Dingell. Thank you, Madam Chair. And thank you, 
Ranking Member Guthrie. And thank you both, Dr. Brooks and Dr. 
Collins, for sitting here this long. And there are a lot more 
after me in the second panel. You are angels for being here.
    I am going to go back to the very beginning of this hearing 
and just make that a public service ad for those that want to 
get us back together and they think, you know, most people have 
been vaccinated. I come from Michigan, which both Dr. Brooks 
and Dr. Collins know, and almost 50 percent of the people in 
Michigan have had at least one vaccination. We still, I am 
told, have close to 100 people in our institution that haven't 
been.
    Our hospitals have been full. Our children are filling the 
intensive care units. Our nurses are stressed to the limit. I 
had to find the money to bury a frontline worker on Sunday who 
committed suicide over COVID. So anybody who thinks that this 
is over, these two can attest to what it has been like in 
Michigan. And it isn't over, and we can't let down our guard. 
So COVID fatigue is what leads to some of this happening. So 
thank you to both of you.
    A lot of us have brought this up, and I just want to build 
on it. I think all of us also have heard from a lot 
constituents too who had chronic fatigue. Because I can tell a 
number of us have met with them. And they are worried about the 
amount of money that is being put into research to have the 
resources needed. I met with a group of doctors. I have met 
with several groups of doctors, both at Michigan University, 
feel more connected to you than single practicing primary care 
doctors. And I think this is really a major issue for us right 
now. The next panel is going to include patients who have 
shared their written testimony, their various experiences in 
going or seeking care in the primary care setting.
    So, Dr. Brooks, can you expand upon what you have been 
talking about? How has COVID impacted primary care physicians? 
And how do we make sure--because a lot of them don't feel they 
have got what they need. How do we make sure they have the 
tools they need to diagnose this condition? And then, where do 
they refer patients?
    Dr. Brooks. Right. You know, thank you so much for also 
paying attention to the healthcare workforce, because they have 
been really slammed basically by this pandemic. And with long 
COVID it is possible that, if large numbers of people 
experience this, we are going to have another problem where we 
need to help providers learn what it is, how to recognize it, 
and how to refer people properly if they themselves aren't 
equipped to care for it.
    So first we need to build the recognition. There is nothing 
more frustrating, I can say from my personal experience, of 
taking care of someone and you don't know what is happening, 
you can't figure it out. And one of our jobs at our agency is 
to try and build that frame where you can begin to fit that 
person's symptoms and signs into something that can bring at 
you, ``I think I know what may help you. You need referral to 
this kind of a specialist.''
    It also means building those specialties. And I think we 
are going to see a lot of subspecialties, some of the ones I 
mentioned before, rheumatology, neurology, pulmonary medicine, 
physical and rehabilitation medicine, you know, really growing 
around this.
    And from my experience in HIV, I can also share something, 
which is maybe we focus a lot on this condition, but its 
benefits echo with other conditions. What we learned around the 
HIV virus benefited our knowledge around many opportunistic 
infections. It benefited infectious diseases in all sorts of 
different areas. Here, too, what we may learn about managing 
and treating this condition will benefit those patients with 
chronic fatigue and ME.
    Mrs. Dingell. I just want to ask both of you in my minute 
left, you are talking about the programs you have. Dr. Collins, 
you have got 200-and-some proposals. Do you have the resources 
you need? How do we--we know this is important. The numbers we 
are seeing here we haven't seen in any other disease. By the 
way, it is really real that people say, people don't believe 
me. Dr. Dunn said that, people have said that to me in the 
meetings I have had over the last few weeks. How do we make 
sure you have what you need? And what do we as a committee need 
to do to support you?
    Dr. Collins. Well, I always appreciate hearing you ask that 
question. I think that $1.15 billion that Congress provided in 
December for us to build this very intense, large-scale study 
is what we need right now. But I don't know exactly what we are 
going to encounter if this goes forward.
    As we have talked about in the course of this hearing, we 
are going to want to institute as many clinical trials as 
possible for interventions. We don't know yet exactly what 
those agents will be or how large those trials will need to be. 
And I can imagine if we get into that in a significant way, we 
may need to find more resources and we may need to come back to 
you and explain why that is.
    But I have to be very grateful for what you have done for 
us back in December to enable us to take this on in a very 
ambitious, large-scale way, which is what the seriousness of 
the problem deserves.
    Dr. Brooks. If I may?
    Ms. Eshoo. The gentlewoman's time has expired, I think.
    Mrs. Dingell. Thank you.
    Ms. Eshoo. Did Dr. Brooks--just very quickly, because we 
still have plenty Members for your panel.
    Dr. Brooks. All I wanted to say was that having this 
hearing today is probably one of the most important first steps 
in raising the awareness that we need in America. And I 
encourage people to take seriously when they have someone they 
know talk about this syndrome. It is real.
    Ms. Eshoo. Thank you, Dr. Brooks. Exactly my intent in 
identifying the issue is one that really needed to be raised up 
to a congressional hearing by our subcommittee. So thank you.
    Now, is the gentleman from Georgia still driving around, 
Mr. Carter, our favorite pharmacist? Not with us? Going, going, 
gone.
    All right. Then I will recognize the gentlewoman from New 
Hampshire, Ms. Kuster, for your 5 minutes of questions. Great 
to see you.
    Ms. Kuster. Great to see you. And thank you so much, Madam 
Chair. I am so grateful for this hearing.
    This past year has been an incredible challenge for 
Americans all across this country. But for those who have had 
COVID-19 and suffered from the lingering effects of this 
disease, this past year has been even more painful. And this 
discussion hits close to home for me and my family.
    My wonderful niece, Laurel, who is an extraordinary 
athlete--she was literally on the United States Ski Team and 
was an amazing ski racer--had COVID just over a year ago today. 
And she continues to have trouble with everything, even the 
simplest activities of daily living. She has to choose between 
taking a shower or making dinner. Otherwise, she was a 34-year-
old and previously very healthy, very competent young woman. 
And I am so proud of her for hanging in there.
    Everything you have talked about today, including doctors 
who didn't take her seriously, has happened in her life. She 
has seen countless doctors and taken endless tests, adding up 
to literally thousands of dollars in out-of-pocket expenses. 
Despite the tests and the preliminary research being done on 
long COVID, her doctors cannot identify exactly what she is 
suffering from.
    As we have heard today, she is not alone. According to NIH, 
more than 50 percent of COVID-19 patients experience lingering 
symptoms longer than 50 days after recovering from their 
initial infection. And the long-term effects are profound. So 
it is critical that we have a coordinated effort here at the 
Federal level. And I really appreciate, Chairwoman Eshoo, for 
you hosting this important hearing.
    Dr. Collins, in December 2020, Congress, we, appropriated 
$1.15 billion in funding to expand research on long-term COVID 
and potential therapeutics. And you have talked a lot about the 
research and the metacohort. I am very curious if you have seen 
any effective treatments.
    I would love to put into the record a recent article from 
The Atlantic about exploring what these treatments might 
entail. And how will you communicate and get the word out to 
the medical community so that we can alleviate the suffering of 
these patients with long COVID?
    Dr. Collins. Yes, it is a very appropriate question. And I 
do hope everybody understands this is not just putting together 
a cohort to study their symptoms and watch from a distance. We 
want to initiate, as soon as possible, interventions. And the 
clinical science's core of this is going to be the best 
experts, including tapping a lot into the people who are 
currently running these long-COVID clinics that you are going 
to hear about in the next panel to see what ideas are out 
there.
    We will, however, want to ensure that, if we are going to 
test a therapeutic, that we do it in a fashion that is 
rigorous, that is well powered, that is placebo-controlled so 
we really will know whether it works or not, because you have 
so much variability in the course of long COVID. Some people 
seem to spontaneously get better over a few months, some people 
don't. And if the only way you are going to really know if your 
intervention work is if you design the trial accordingly, we 
will be doing that.
    I mentioned earlier we are already running a trial about 
whether anticoagulants in the convalescent period might be 
beneficial and certainly some ideas about immunosuppressants 
that could be tried as well. Beyond that, I haven't see the 
article you mentioned in The Atlantic. There are ideas floating 
around, but we are going to need to prioritize them about which 
are the most promising, make sure we have the appropriate 
clinical trials and master protocols put together, and then we 
are going to go and see what works as soon as possible to try 
to come up with things that we can advertise to the clinicians 
around the country as here is new information you might want to 
know. CDC will help us a lot with that because of their 
connections with the clinical community out there.
    Ms. Kuster. And I am curious, as well, not just 
interventions with therapeutics or medication but also 
treatment. This article related to breathing techniques that 
might be helpful. Have you heard about any other types of 
treatments that don't entail intervention but just entail 
helping the person live with the situation?
    Dr. Collins. Yes. Certainly, this kind of pulmonary 
rehabilitation, which has been used for other conditions, does 
seem to provide some benefit to patients, cardiac 
rehabilitation for people who are primarily suffering from 
things like palpitations and fatigue. And also interventions to 
help with the brain fog, similar to what has been done for 
people with concussions, do seem to provide benefit.
    Again, I think you are going to hear from the people 
running the post-COVID clinic in the next panel about things 
that they have tried. But it is still kind of early days. We 
are all just trying to see what could we try and did it work. 
And you want the most rigorous, large-scale data as soon as 
possible. That is what I think we can contribute with this 
metacohort.
    Ms. Kuster. Well, my time is up. But I thank you all for 
everything you are doing to get to the bottom of this.
    And I yield back.
    Ms. Eshoo. The gentlewoman yields back.
    I am always struck by the term ``novel coronavirus.'' We 
keep learning. There is a reason it is called novel; we keep 
learning every day. And hopefully, today's hearing advances 
that learning and how we can apply it best.
    I just want to say, we don't have any more Republican 
members of our committee in the lineup, so I don't want anyone 
to think that I am skipping over them. But we will continue on 
and it will just be from our side of the aisle, unless someone 
shows up that didn't have the opportunity to question.
    So it is a pleasure to recognize the gentlewoman from 
Illinois, Ms. Kelly, for her 5 minutes of questions.
    Ms. Kelly. Thank you so much, Madam Chair.
    Dr. Collins, when we talk about long COVID our constituents 
are saying that they are no longer able to work due to fatigue. 
How do we help employers understand the plight of their 
employees' experience in long COVID to ensure they are not 
discriminated against in the workforce and are able to remain 
productive citizens if they chose to do so? And thank you for 
being here.
    Dr. Collins. Thank you for the question. It is really 
important that we figure out ways to support people who are 
going through this prolonged period of fatigue that makes it 
impossible for them to work full time or maybe even to work at 
all. And we know that does happen to a substantial number of 
individuals with long COVID. And that means we need to figure 
out how to get this information into the hands of Social 
Security, for instance, in terms of disability claims.
    By the way, it also means we need to be sure we have a good 
connection with CMS so that the coverage for medical expenses 
doesn't end up bankrupting individuals who are already going to 
be in a tough place because of this illness. Both CDC and NIH 
have been working closely with CMS on that issue aiming to try 
to come up with the usual thing you need, which is an ICD-10 
code so that these kinds of reimbursements will begin to take 
place more readily.
    Again, I think employers generally are not going to be very 
sympathetic unless they are totally convinced that this is 
something that is medically established. So the docs are going 
to have a lot to do with that, which is why what we have been 
talking about a minute ago in terms of getting information to 
clinicians so that they don't brush these symptoms off as if it 
was something not so serious is going to be critical.
    But I should ask Dr. Brooks also to address your question, 
because I think the connection CDC has in here is really 
important with employers, with Social Security.
    Dr. Brooks. Thanks, Dr. Collins. And thanks, 
Representative. That is a really insightful question. We spend 
a lot of time, first of all, working with the employment 
community to show that people who may be disabled--and I am not 
going to say that people with this condition are disabled--but 
people who are challenged by medical illness are still able to 
work and to work with them to find ways to help them work.
    We have got a year of experience living on Zoom--as we are 
doing right this minute--and we are finding ways to help people 
do their job and be gainfully and meaningfully employed outside 
of the standard workplace.
    And then, as Dr. Collins was mentioning, for people who are 
down for the count, we have got to make sure that we can 
clarify for people this is a real condition that people are 
living with and to take the symptoms seriously. This is one of 
the driving forces for us to get these interim guidelines 
together so we can begin to provide clinicians with a way to 
describe what is going on.
    I hope you will hear this afternoon from our colleagues at 
UCSF and Yale some of the challenges they may have faced in 
terms of filling out disability claims or off-work claims and 
the ways that they are working to address that. But it is 
critical that people who have been affected by this disease are 
able to be taken care of and, if that means they are unable to 
work for a period of time, that we are able to support them 
then.
    Ms. Kelly. Thank you so much. And I know my other 
colleagues have been waiting a long time, so I will just ask 
one question. Thank you so much.
    Ms. Eshoo. The gentlewoman yields back. That is so generous 
of you.
    I am going to go back to the gentleman in the car. I called 
you our favorite pharmacist, the gentleman from Georgia, Mr. 
Carter, for your 5 minutes of questions.
    Mr. Carter. Thank you, Madam Chair. I appreciate this. And 
thank you for bearing with me.
    Dr. Collins and Dr. Brooks, I thank both of you for being 
here. This is extremely important.
    I have got a staffer who has been diagnosed with long 
COVID. And that staffer has been--that individual has suffered 
from severe anxiety, fatigue, long-lasting loss of smell and 
taste, and these are very serious issues, and I am very 
concerned. And concerned, obviously, because it is someone 
close to me.
    I wanted to ask you--the staffer in my office, she says 
that many of her long-COVID symptoms dissipated after she 
received the vaccine. Is the CDC or the NIH aware of any reason 
the vaccine may help with long-COVID symptoms? Dr. Brooks?
    Dr. Brooks. That is a great question. Thank you. And I will 
say these were fascinating reports when they began to come out. 
We have talked a little bit about this, so I don't want to go 
over all of that territory, other than to say there are some 
emerging research data that suggests there may be something 
there. But we have really got to look at it more closely.
    The mechanisms are--there are multiple things that could be 
going on. I think the ones that I like the most are the idea 
that the vaccine is bringing benefit in terms of either 
controlling this, if it is an ongoing active infection that we 
are not recognizing, or doing something to get the immune 
system back on track to where it should have been.
    Also, this is a great reason for people who are having 
post-COVID to get vaccinated, if they haven't been vaccinated 
already. We can't guarantee that this positive experience some 
people have reported is one that everyone will have, but I 
certainly hope it would bring people off the sidelines to get 
vaccinated if they are hesitant.
    Mr. Carter. That is great.
    Dr. Collins, are you aware of any studies that are being 
done about this?
    Dr. Collins. Yes. There is one small study that has been 
published as a peer review, but it is 44 individuals where 
there was overall a small improvement in those who got 
vaccinated versus those who didn't. But also, there is a 
patient support group called Survivor Corps, and they did a 
survey, I think of more than 500 individuals who had had long 
COVID, got vaccinated. Forty percent of them reported some 
improvement, which was encouraging to hear. And relatively few 
reported the opposite, of having a worsening of their symptoms.
    What exactly that means as far as the mechanism, I am sure 
you are wondering about that too because we all are. Does that 
mean that those individuals with long COVID still have a low-
level viral infection that we haven't been able to quite 
discover and that the vaccine basically gives their immune 
system the kick it needs in order to take care of that residual 
virus? Or is it that they have an autoimmune condition already 
because of that COVID infection and the vaccine interrupts with 
that? We don't know. Those are theories.
    Mr. Carter. I am going to kind of go off script here, 
because this is something that--and I never try to get personal 
in any of these hearings, but I have got a dear friend who is 
suffering right now with psychological, mental problems as a 
result of COVID. What is going on with that? Dr. Collins, do 
you know? I mean, he has had to be admitted, and I am just 
worried to death about him.
    Dr. Collins. I am very worried about that because we are 
seeing instances--first of all, let me say anxiety and 
depression is a very common feature of long COVID. But there 
are instances of actual induction of new psychoses in 
individuals who previously were normally functioning, who 
actually fall really into a much more serious psychiatric 
illness. We assume this must be some way in which this virus 
has interfered with the function of the brain, maybe by 
affecting a vascular system or some other means of altering the 
way in which the brain normally works. But we have so little 
information right now about what that actual anatomic mechanism 
might be. And that is something we have to study intensively.
    But you are so right, this is a big part of long COVID, is 
the mental health consequences. We shouldn't just talk about 
shortness of breath and palpitations. We have got to talk about 
the mental health issues.
    Mr. Carter. Dr. Brooks, any comment on that?
    Dr. Brooks. I completely agree that mental health is often 
the last breath and a discussion of what we need to address 
when often in a condition like this it needs to be the first 
thing we bring to the front. I hope your friend gets the care 
they need. And I am very, very sorry to hear how ill they are.
    Mr. Carter. I tell you, it is just obvious--I am very, very 
concerned. And I just--has the vaccine--to be quite honest with 
you, I don't know whether he has gotten the vaccine or not. Is 
this another instant if he was to get the vaccine? Has it shown 
improvement for these people?
    Dr. Brooks. I think from what Dr. Collins described, there 
is a possibility it will help, and there is not a lot of 
indication that it is going to do harm. And we know that in the 
long run it will protect him against the possibility of 
reinfection. I would do it.
    Dr. Collins. Yes, I am with you.
    Mr. Carter. Good.
    OK. Madam Chair, thank you very much. I appreciate it. And 
I yield back.
    Ms. Eshoo. The gentleman yields back.
    It is a pleasure to recognize the gentlewoman from 
California, Ms. Barragan, followed by Representative Craig from 
Minnesota.
    Ms. Barragan. Thank you, Madam Chairwoman.
    The USC school--the Keck Medicine is reporting that 1 out 
of every 10 COVID-19 patients at Keck Medicine of USC is a 
long-hauler. And for them, they say that this statistic is 
pretty nationwide, about 10 percent of COVID-19 patients have 
these long-haul symptoms. At Keck, they say most of the long-
haulers are between the ages of 20 and 40 years old, which is 
quite remarkable when you think these are young people, many of 
them maybe healthy.
    Is there any data or information that we have about why 
maybe in southern California, I don't know how common it is, 
that it is impacting younger people between 20 and 40 more than 
others?
    Dr. Brooks. If you want, I can start with that, Dr. 
Collins.
    Dr. Collins. Sure.
    Dr. Brooks. And, Congresswoman, thank you much for that 
important question. Let me point out one thing that is 
important to have in the back of your mind, is that among the 
persons affected by COVID in this country, the largest numbers 
of new infections are among people in that age group, 18 to 39. 
So it is not a surprise necessarily that they would be 
overrepresented in the persons who are experiencing post COVID 
as well.
    Having said that, I still think it merits close attention, 
because it is an unusual signal. And I hope folks are, you 
know, going to begin focusing more on the age differences as 
well as some of the others that we have raised before.
    Dr. Collins. Yes, I agree with that. When you look at what 
is the likelihood that somebody who was just diagnosed with 
COVID-19 is going to go on to long COVID, it looks as if it is 
a bit higher for older people. But on the other hand, there are 
more young people getting infected. So if you go through the 
mathematics, you can see why it is that long COVID seems to be 
particularly prominent now in younger people, who may not have 
been very sick at all with the acute infection. Some of them 
had minimal symptoms but now are turning up with this.
    That 10 percent number that USC is reporting, that is 
pretty typical for what a lot of the studies are showing, 
although there is quite a lot of variability, some as high as 
30 percent, some lower than 10. One of the things we really 
need to get a better fix on is what is that percentage when you 
have a very large study and you can control for all of the 
other correlates that might play a role there.
    But, you know, here we are having this hearing about is 
this really an important issue. Think about this for a minute: 
We have got 32 million people who have been diagnosed with the 
acute infection of SARS-CoV-2, COVID-19. Let's say 10 percent 
is right. That means there are 3 million people who are going 
to be affected with this or already are and whose long-term 
course is uncertain and may very well end up being people with 
chronic illnesses. That is why this is such a serious issue.
    That is why I am grateful to you all on this subcommittee 
and in the Congress for taking this so seriously and giving us 
the opportunity to throw everything we have got at it to try to 
understand this and try to interfere with the diabolical nature 
of this virus to not only get you once in an acute illness but 
also get you again as you think you are getting better and 
maybe don't. So thank you for the recognition of that. I can't 
overstate how serious this situation is for the health of our 
Nation.
    Dr. Brooks. Let me add, if I may, just one thing. This is a 
great opportunity to remind young people they are not immune to 
this, right? This is really the audience you want to reach with 
``vaccination is something you should strongly consider, yhis 
affects people like you.''
    Ms. Barragan. Right. And that is a good reminder, 
gentlemen, about what we are hearing and read about these days, 
that more and more Americans are not going to get their second 
dose because they are worried about any side effects that may 
last a day or two on, you know, a headache or aches and pains. 
And so this sounds like the alternative of a possible long-term 
impact is going to be a lot worse. And so I am encouraging 
those in our community to go get that second shot if they have 
not yet.
    You know, I represent a district that is almost 90 percent 
Latino, African American. We have been hit super hard by COVID-
19. Many are low income, many don't have access to services 
they need, maybe they don't have full access to healthcare.
    Dr. Brooks, you have already touched on how the social 
determinants of health affect people in underserved communities 
who have long COVID. And I know that the CDC is very interested 
in addressing social determinants, not only regarding COVID but 
also more broadly. Dr. Brooks, do you believe that Congress 
should be doing more to address social determinants of health, 
including fully funding the CDC's social determinants of health 
program as a strategy to help those most impacted by the 
pandemic?
    Dr. Brooks. I agree with you completely. The social 
determinants of health are critical underlying causes for what 
may be driving some of the things that we are seeing. 
Unfortunately, that is an area, the funding part, that is a 
little out of my expertise. But what I want to do is I will 
take that back to our folks and get an answer for you. I want 
to make sure we address the question you are answer--you are 
raising, rather.
    Ms. Barragan. Fantastic. Thank you.
    With that, Madam Chairwoman, I yield back.
    Ms. Eshoo. The gentlewoman yields back.
    A pleasure to recognize the gentlewoman from Minnesota, 
Congresswoman Craig, followed by another one of our outstanding 
doctors from the State of Washington, Congresswoman Schrier.
    So, Angie, take it away. You have 5 minutes.
    Ms. Craig. Thank you so much, Chairwoman.
    It is really an honor to be here to talk to both you, Dr. 
Collins, and Dr. Brooks.
    We have heard you both share that long COVID is such a 
complex disease that we don't know so much about it at this 
point. So many different symptoms that involve many different 
organ systems, from the lungs, to the heart, to the brain. We 
know that these complex conditions often require advanced and 
multidisciplinary care that might only be available at some 
larger institutions.
    In my home State of Minnesota, of course, we are fortunate 
to have world-class facilities that help people suffering from 
long COVID return to--to help them try to return to that pre-
COVID life. Programs such as the COVID Activity Rehabilitation 
Program at the Mayo Clinic provide comprehensive rehabilitation 
services and mental health support.
    Dr. Brooks, with such complexities, with such 
multidisciplinary medical care needed, where should my 
constituents start in terms of the setting that they are 
looking for to receive, generally seeking care for long COVID?
    Dr. Brooks. You know, you raise a really important 
question, because in an evolving disease like this, we really 
want to get people to the right place as soon as we can so they 
get the appropriate care.
    As before, I would recommend that people first seek care 
with their primary care physician. It is our duty to raise 
awareness in the frontline provider community that this is a 
real condition, that it exists, it may be misunderstood, but to 
recognize that there is something there, and to use that as a 
cue to seek referral to a specialty center.
    Now, for the time being, we may have to work in that 
system, but I hope one day we are able to move to a system like 
we used for HIV now, another complex disease, but where we were 
able to diffuse the knowledge and actually bring it to people 
further away from the centers of academia.
    Ms. Craig. Dr. Brooks, just stay with me for one more 
minute, what is the CDC doing to help inform those primary care 
providers on long COVID and to ensure that those appropriate 
services are available?
    Dr. Brooks. So we have regular webinars and phone calls to 
which we invite clinicians and care providers, and actually 
pretty much anyone is welcome, but it is intended for that 
audience to bring them up to speed about the latest knowledge 
around COVID-19, but also in this case long COVID.
    In addition, we have drafted interim guidelines to assist 
in the early diagnosis, recognition, management, and referral 
to services and how to do that and also how to help patients 
engage with support groups that may be out there and can offer 
some other options for them.
    Ms. Craig. Thank you so much.
    I want to ask Dr. Collins the next question. It is nice to 
see you again, and thank you for the great tour of NIH before 
COVID.
    The majority of NIH funding flows through academic medical 
centers who are often, obviously, leading the way in addressing 
long COVID.What is happening at NIH or other Federal agencies 
to learn from these academic medical centers to assist you in 
the development of care models for long COVID?
    Dr. Collins. Well, they are most certainly critical 
partners for us, and you will hear from a couple of 
representatives in the next panel about how academic centers 
have tried to pull together the kind of multidisciplinary care 
that is necessary for long COVID. One of the things I worry 
about, relative to your earlier question, is if people start 
bouncing around from specialist to specialist and nobodyis 
actually coordinating the big picture, then long COVID is not 
going to be well taken care of because almost nobody with long 
COVID has one symptom or one organ that needs to be attended 
to. It is multicomponent. And that is where the academic 
centers trying to put together these long-COVID clinics that 
have access to multiple expertise is going to be really 
important.
    Those 273 applications I mentioned that we are reviewing 
right now, a very large number of them are from academic 
centers that do in fact bring their expertise and their hopes 
and dreams of helping with this situation as they have been our 
partners in many other situations. They are going to be that 
here as well, although they have to show what they can do. We 
won't be able to fund all of them, not with that number, but we 
are going to build on that expertise as well as bringing in 
other kinds of insights from small businesses and from other 
government agencies like CDC and FDA and really try to bring, 
as we have done in therapeutics and vaccines, all of the 
players around the same table to solve a really hard problem.
    Ms. Craig. Well, I just want to say thank you to both of 
you, Dr. Collins and Brooks, for a grateful American public. I 
know it has been incredibly difficult. Thank you for your 
leadership during these difficult times.
    With that, Madam Chair, I will yield back.
    Ms. Eshoo. The gentlewoman yields back.
    The Chair is very pleased to recognize another one of our 
outstanding doctors on the committee, such value added since 
she has come on: Dr. Schrier, from the State of Washington. You 
are recognized for 5 minutes.
    Ms. Schrier. Thank you for that kind introduction, Madam 
Chair.
    And thank you, Dr. Collins and Dr. Brooks, for joining us 
today and giving your insights about what we know about long 
COVID and what we don't. It will not surprise my colleagues 
that, as a pediatrician and a mom, I am going to focus on 
children today. Because we have talked for over a year about 
how we are so fortunate that children are only minimally 
affected by COVID-19, that it is changing a bit with the 
B.1.1.7 variant, the fact that adults with no symptoms or very 
mild symptoms can still have pretty devastating and life-
altering COVID symptoms really begs the question about 
children's risks for long COVID and whether we are a bit too 
complacent about how we are managing their risk. And I am 
thinking about schools and camps.
    So my first question is for Dr. Brooks. Could you just 
quickly list, just based on what you know so far--and I know it 
is limited--what are some of the ways that long COVID seems to 
present in children, just so we have our radar up?
    Dr. Brooks. Right. Right. So the data that I am aware of, 
for some of the symptoms are the ones you see in adults as you 
would expect in, particularly, pulmonary conditions, persistent 
shortness of breath, maybe cough, as well as persistent 
fatigue. There is also some evidence that the experience--what 
is called a brain fog, but it is probably some issue--probably 
neurocognitive in nature, and it is important for kids when 
they are growing and developing that we understand what is 
happening there because we don't want that to impair their 
ability to learn and grow properly.
    Those would be the main symptoms that I am most aware of to 
look for.
    Ms. Schrier. And those are so interesting because we do see 
symptoms like that frequently, and I will get back to this, but 
it may raise the question of whether part of the workup now 
becomes titers in those kids. Now, both of you--I will start 
with Dr. Collins, you have said many times and we doctors on 
the call have said that the best way to prevent long COVID is 
to get vaccinated. And I have to note that Pfizer submitted a 
request for emergency use authorization for children 12 to 15 
years old several weeks ago.
    Do you have any idea why we are not moving as quickly with 
that approval as we did for adults? Because we had that, you 
know, out to the public, I think, within a week or so. And I, 
as a mom of a 12-year-old, and I know moms everywhere are 
wondering, especially with long COVID, when can our kids get 
vaccinated?
    Dr. Collins. Very good question, Dr. Schrier. And I, as a 
grandfather of a 14-year-old, am wondering the same question. 
So, yes, I know Pfizer did submit their data and is seeking EUA 
for kids 12 to 15. FDA has been looking at it. I think, to be 
fair, it took FDA 2 weeks with the adult data before they 
convened their advisory committee and had the public 
discussion, but it has been a little longer than that.
    I don't have insight into what is happening in the internal 
workings of the FDA. I am sure they have been a little busy 
with this J&J circumstance, but I am hopeful, as you are, that 
they will come forward pretty soon with a rendering of a 
judgment here, and they will have to convene their public 
committee so that everybody gets to look at this. Obviously, 
everybody wants to be sure, if we are talking about kids, that 
there's no new safety concerns there. But, yes, wouldn't it be 
great if we could do that and not have to wait till the fall 
when school starts up, to get started now this summer 
immunizing those high school kids and middle school kids, too? 
I would love it.
    Ms. Schrier. It sure would be nice. Summer camp is coming 
up. So I have another question for you because we are doing our 
own research here. Israel is a country that has medical records 
on everybody from the day they are born. They had high rates of 
COVID like we did. They also now have astounding rates of 
immunization. I am just wondering if we are kind of 
collaborating with Israel on the question of long COVID.
    Dr. Brooks, sorry. Dr. Brooks.
    Dr. Brooks. Sure, yes. We certainly follow the Israeli 
literature closely because the benefit that you just described 
are allowing them to pour out new information to share with 
people is very valuable. We also work with the World Health 
Organization on the long COVID effort, and it is probably 
primarily through that relationship with WHO, who are also very 
vested in this because this is a problem seen everywhere in the 
world. I just want to mention that this is not unique to 
America. It makes common sense, but it is being seen in every 
country pretty much.
    So we--I have spoken to Israeli colleagues through that 
relationship and also a panel that is convened regularly by the 
European CDC where they bring leading CDCs from other countries 
together. Israel is always in that group. You remind me that I 
am going to want to talk about long COVID in our meeting coming 
up shortly.
    Ms. Schrier. Well, thank you. Thank you both for this 
really important meeting and your attention to it. Thank you.
    I yield back.
    Ms. Eshoo. The gentlewoman yields back.
    The next two Members that I will recognize, first, the 
gentlewoman from Massachusetts--again, high value added, new 
member of our subcommittee, we are thrilled to have her--
Congressman Trahan. You are recognized for 5 minutes.
    Can you hear me?
    Mrs. Trahan. Thank you, Chairwoman Eshoo. Yes, can you hear 
me?
    Ms. Eshoo. I can.
    Mrs. Trahan. OK. Terrific. Well, thank you, Chairwoman 
Eshoo, for holding this illuminating and important hearing. And 
my thanks to Drs. Collins and Brooks. You know, I want to just 
spend a minute elevating the story of one of my constituents, 
Lauren Nichols. She is a 33-year-old former athlete----
    Ms. Eshoo. Can I--excuse me for interrupting. We can't see 
you. I don't know if it is just my screen, or is it everyone 
else's? We can hear you, though.
    Oh, there you are. Good.
    Dr. Collins. I think it is a weak signal.
    Mrs. Trahan. All right. OK. Sorry about that. So Lauren is 
a 33-year-old former athlete, runner, and hiker from 
Massachusetts who has been suffering from long COVID since 
March of last year. She first developed the symptoms on March 
10 of 2020, and her initial symptoms were severe neurological 
and gastrointestinal issues, which then escalated to severe 
shortness of breath a few days later. When Lauren tried to get 
a COVID test through her primary care doctor, the answer she 
received was not at all encouraging. In fact, I, quote: ``You 
are young, and you will be just fine if you contract COVID.''
    And she was denied a test. But as her symptoms worsened, 
Lauren sought a second medical opinion where she, again, was 
met with skepticism from a physician who did not believe the 
severity of her gastrointestinal issues or that they were even 
related to COVID. But due to her own advocacy, Lauren 
eventually received a COVID test and was diagnosed with the 
virus.
    But in the weeks that followed, Lauren developed pneumonia, 
painful colitis, and due to the lack of support from those she 
sought medical help from, she developed depression and became 
suicidal. Months later, she developed eye shingles and is now 
visually impaired. She started to have seizures and even a 
stroke, all due to the lingering effects of COVID-19. Although, 
she is insured, Lauren has spent more than $12,000 out of 
pocket for her [inaudible]. Long-COVID patient developed 
fatigue or MECSF, which has been raised by [inaudible]. Dr. 
Anthony Fauci last summer stated that many COVID-19 [inaudible] 
patients [inaudible] significantly increasing the number of 
those patients across our country.
    So, Dr. Collins, historically research into clinical trials 
and treatments for MECSF have gone underfunded at NIH, leaving 
many patients to suffer physically [inaudible].
    Ms. Eshoo. Your voice is--Lori, can you restate your 
question?
    Mrs. Trahan. [inaudible] Congress appropriated $1.15 
million for research for the agency, but heading to DC.
    So, Dr. Collins, this question is for you. As NIH leverages 
its research on MECSF to better understand the intersection of 
MECSF and COVID-19 syndrome [inaudible]. When can patients like 
Lauren and so many others expect developed from COVID? Did that 
not come through? That question not come through?
    Ms. Eshoo. We are having a problem with your audio. It is 
really breaking up in the car.
    Dr. Collins, did you get the gist of the question?
    Dr. Collins. I think I got the general gist, particularly 
asking about a CSF or MECSF and the relationship to long COVID 
and the need for research on both of them, and I agree with 
that. I have been very concerned for several years about the 
lack of understanding of MECSF and what the mechanism is that 
causes individuals to suffer from this oftentimes years of 
fatigue that are sufficiently severe to keep people almost 
bedridden.
    We do have a lot more research going on on that. We funded 
no less than four centers of excellence to work on CSF. Our own 
intramural program at NIH has a big program bringing patients 
to our clinical center for intense study with CSF, and the same 
investigators are now studying long COVID with the same 
mindset.
    So, if there is an overlap between this, I think we are 
going to discover what that might be. And my hope would be that 
the fact that we are now able to put a lot of resources into 
studying the long COVID circumstance where we know what the 
inciting agent was--we know what the virus was--we should learn 
something that will spill over in a useful way into our 
understanding of CSF, and we will be able to offer something 
more successful to those individuals who have suffered a lot 
for much too long.
    Mrs. Trahan. Thank you, Dr. Collins, and I appreciate the 
committee's patience. I apologize for the in and out and the 
weak signal. I will submit my question for Dr. Brooks--I will 
submit it for the record. Thank you.
    I yield back.
    Ms. Eshoo. Wonderful. Thank you. We certainly understand, 
you know, all of the glitches that are possible and sometimes 
probable out there, but we want to make sure that we got your 
question in and submit--all Members can obviously submit their 
written questions to our witnesses.
    Pleasure to recognize the gentlewoman from Texas, Mrs. 
Fletcher, for your 5 minutes of questions. Great to see you. 
Thanks for your patience.
    Mrs. Fletcher. Great to see you, and thank you so much for 
holding this hearing, Chairwoman Eshoo. This is really 
critical, as so many of my colleagues have said before me 
today, and I am looking forward to our next panel as well. But 
I think that our witnesses in this first panel have really been 
excellent in making it abundantly clear that long-term COVID, 
long COVID, is real. It can be debilitating. I really 
appreciate it. The answers just now about comparisons with CSF, 
that is certainly something that we have experienced here in 
our community, a lot of folks and those challenges, but, you 
know, I am very concerned, as I think has been made clear 
today, that once we get past, you know, this pandemic or get to 
the next phase of this pandemic and the majority of people are 
vaccinated, we are still going to have a health crisis on our 
hands. Certainly that has been made clear, also my colleague 
Debbie Dingell mentioning the status of things in Michigan, 
certainly we still have our challenges down here in Houston and 
in Texas.
    So I wanted to just use the time that I have to see about--
to follow up on sort of two things. Dr. Collins, in your 
testimony today, both written and in response to questions from 
some other colleagues, you talk about individuals facing 
skepticism about what they are experiencing. And I think, as 
some other people have mentioned, there are also real 
challenges to identifying as a patient, you know, whether these 
are symptoms, what to expect, how to properly categorize what 
you are experiencing.
    So I am wondering, actually, if both of you could just 
touch on a little bit more anything you haven't had a chance to 
say about how we educate the public about how to recognize 
symptoms and how to access care. And, obviously, I am 
particularly worried about those areas where there may not be a 
COVID-19 long-hauler clinic.
    So really understanding what patients can do and how they 
can evaluate and get access to care and also how health workers 
are equipped with the resources and training to deal with 
those? So I would love your thoughts on those issues.
    Dr. Collins. Well, first, I would say this hearing is a 
good step in the right direction, and so thanks to the 
leadership for putting this together, and I hope, because the 
press tends to listen to these things, that this will provide 
another opportunity for people to be informed about long COVID. 
It is a real and serious condition.
    And let me just turn, though, now to Dr. Brooks because CDC 
is in such a critical place in terms of trying to both do the 
public education and the provider education so that people 
aren't faced with this terrible circumstance of not only having 
a terrible condition but not being believed that you have 
anything wrong with you.
    Dr. Brooks. Yes. Thanks, Dr. Collins, and especially, 
Congresswoman, for the question, the insight here. You know, 
one of the things we are doing first is trying to make sure 
that clinicians are aware that this exists and that it is real 
and how to recognize it. And we are doing that through a 
variety of different means of webinars, phone calls, and 
developing interim guidance. At the same time, we want to make 
sure patients are aware that, if they have something, to seek 
care.
    We want them to seek primary care first to make sure that 
it isn't something else. There are a lot of things that may 
look like some of these early symptoms, and those can be taken 
care of, but if it is not and they are concerned that it could 
be long COVID, then to refer them to the proper place to get 
that kind of care. Although it is primarily centered in urban 
and academic centers presently, as we learn more I fully expect 
that it will be basic care for people with long COVID. We will 
be moving out into community health centers, secondary and 
tertiary hospital centers so that people will have access to 
the services that they need, but the burden question is a 
burning one: 32 million Americans so far have been infected, as 
Dr. Collins referenced. Even if a small percentage of them, 10 
percent, have this, that is lots of people. That is millions of 
people. So we need to be prepared that this will be with us for 
a long time. It could be substantial.
    Mrs. Fletcher. Well, thank you so much for your insights 
and for your testimony here today. I really appreciate the 
emphasis that you are placing on this and on communicating with 
our communities, and certainly we here in Houston and Harris 
County are very interested in being a part of the research and 
the work that you are doing. And I know there is a lot of 
collaboration going on from folks here in the Texas Medical 
Center and beyond, you know, working hard to try to address 
these issues.
    And, you know, the one other thing that I would love to 
just hear you touch on if either of you have additional 
thoughts, Dr. Collins, you mentioned earlier about the ARPA-H 
proposal and, in the short time we have left, if you have any 
additional thoughts you haven't shared on that. I think it is 
really exciting.
    Dr. Collins. Well, I do, too, as you might have guessed 
from my earlier comment. This is an opportunity to take some of 
the lessons that we have learned, particularly with COVID-19, 
but going back to other things we have done that have been out 
of the order in terms of really rapid progress in areas that 
require a lot of different disciplines to get together and move 
forward in a fashion that has been pioneered by DARPA and the 
Defense Department, of which we could bring to the health arena 
with great benefit.
    So I am very excited if this is, in fact, embraced by the 
Congress and the appropriations process that we are getting 
into for fiscal year 2022, if we could stand up this new unit 
at NIH, that would be doing some pretty breathtaking things 
across the board in many different areas--not just infectious 
diseases, but other things as well. So thanks for asking.
    Mrs. Fletcher. Well, thank you so much. I see I have gone 
over my time. It is very exciting. I look forward to working 
with you and Chairwoman Eshoo on these matters.
    Chairwoman, thank you so much for allowing me this time and 
for holding this hearing.
    Ms. Eshoo. Absolutely. It is a pleasure. We have two 
Members that are waiving on to our subcommittee, and we always 
welcome them and any Member that wants to join us from the full 
committee to waive on, and they will be the last two that I 
know of to question this panel. So, Drs. Collins and Brooks, 
you are going to have your late lunch shortly.
    So, at this time, I would like to recognize the gentlewoman 
from Illinois, Ms. Schakowsky, who very often waives on, and we 
are always happy to have her. You have 5 minutes.
    Ms. Schakowsky. Thank you so much, Madam Chair, for 
allowing me to be here.
    I am--first of all, just want to thank both Dr. Brooks and 
Dr. Collins. Makes me so proud that within our government and 
our public health system and our scientists are doing so much. 
I really appreciated that when Dr. Fauci got his vaccine, he 
called it the NIH vaccine, underscoring what we do together as 
a country to support your wonderful work. So thank you for 
that.
    But I have to tell you that I am very worried. You know, we 
have right now vaccines and therapeutics that are affordable 
because we are doing that during what we call the COVID crisis, 
but after that, for the long COVID, are people going to be able 
to afford it? Are people going to be able to get the help they 
need?
    I know you have talked about just proving that they are 
sick in the first place is a challenge, but let's say that they 
are. We have seen through COVID the disparities, communities of 
color, individuals who are more infected, people in lower-
income communities. We have already seen Pfizer report to their 
stockholders and investors that, oh, this is going to be a good 
year because we are going to have these vaccines boosters every 
year for people, and we are going to--so once this designated 
timeframe, it has passed, are people who have long COVID going 
to be able to not only access the doctors and get the treatment 
but be able to afford this?
    I am very worried about this and Big Pharma's proclivity to 
profit on what is happening right now.
    Dr. Collins. So I wish I could get my crystal ball to be a 
little less cloudy here as we try to look forward where we 
might be in 6 or 9 months. I think in 6 or 9 months, we will 
have a better understanding of what the actual mechanism is of 
long COVID. Maybe that is a little early to be really, really 
clear, but I think we will have some pretty good clues, and 
that will lead us in the direction of treatments, but then we 
will have to figure out do they actually work in rigorous 
trials.
    So let's say a year from now, we might begin to really get 
a sense of what is optimum medical management of people 
suffering from long COVID and who is going to pay for it. We 
have already started that conversation with CMS because, as you 
know, a lot of what happens with third-party payment follows 
CMS's guidelines for both Medicare and Medicaid, and I think 
that is going to be critical going forward. Because you can 
imagine the tragedy that will ensue if we come up with a way to 
treat long COVID, but it happens to be a fairly expensive agent 
and it is not covered by third parties, then we are hitting 
people with one more terrible outcome. We can't let that 
happen.
    I know CDC has worked closely also with CMS in this space, 
and this is a place where our three agencies plus FDA are going 
to need to be in lockstep to make sure we don't stumble with 
the ability to find things that are going to help people that 
are affordable.
    Ms. Schakowsky. Well, I think what you can do to help us is 
to identify the symptoms that are almost certainly connected to 
COVID, because I think that there may be some resistance to 
even identify something as COVID-related.
    Dr. Collins. Yes. I think that is right, and I think CDC is 
very much trying to push into that space of saying what really 
is our case definition here that ought to be reimbursed.
    Dr. Brooks. I have to agree. Establishing case definition 
is fundamental to the issues that you are talking about, 
Congresswoman.
    Ms. Schakowsky. And that is what you folks do, right?
    Dr. Brooks. Yes.
    Ms. Schakowsky. OK. Well, I am just so grateful for all of 
the work that has been done in the public sector by people like 
you who are so dedicated, and I just appreciate it, but, you 
know, women, by the way--and we are going to hear some 
testimony and we have had testimony at this committee--are 
often also underlistened to----
    Dr. Brooks. Oh, yes.
    Ms. Schakowsky [continuing]. When it comes to health 
issues. So it is an issue for women as well to make sure that 
we are accepted for the treatments that we need and that they 
are available and affordable. So thank you once again.
    And I yield back.
    Ms. Eshoo. The gentlewoman yields back. And I would say 
back to the gentlewoman, how about just across the board 
relative to women and speaking and really being paid attention 
to? We push forward. We are changing that every day.
    It is now a pleasure to recognize the gentleman from 
Pennsylvania, a great friend, chairman of one of our--another 
very important subcommittees at Energy and Commerce, 
Communications and Technology, and he has been with us since 
the gavel went down this morning. So thank you, Mr. Doyle, and 
you have 5 full minutes. I won't hammer the way you do. How is 
that?
    Mr. Doyle. Madam Chair, I want to thank you so much for 
holding this hearing and for allowing me to waive on, and it is 
great to see Dr. Collins and Dr. Brooks here and the great work 
that they do.
    Peter Welch brought up a good point about being able to 
diagnose and having tools to diagnose long hauler. I have--one 
of my sons is a long-hauler going on his fourth month since he 
was infected. Young, athletic type, wrestler, body 
weightlifter, I mean, just in perfect physical condition, and 
to see how debilitated he has become. He just took disability 
from his job, and he works in pharma, and he has got a great 
job and two of our grandkids, and it has been tough to watch.
    But because he is a COVID long-hauler, I have been in touch 
with a long-COVID researcher in California, Dr. Bruce 
Patterson, who is the former medical director of the Diagnostic 
Virology at Stanford, and Dr. Patterson has a database of long-
COVID patients and blood samples of some 4,500 now. Here is an 
article entitled ``Immune-Based Prediction of COVID-19 Severity 
and Chronicity Decoded Using Machine Learning,'' which was just 
accepted by peer review, and it is going to be published in one 
of the immunology journals soon.
    And with his model, he has been able to accurately predict 
long-haulers through the 14 cytokines related to COVID using a 
simple blood sample from a patient. I hope this is something 
that NIH is interested in, and I guess my question is, how do 
we make sure that when we have researchers that have, you know, 
breakthroughs like this that it is widely disseminated and that 
NIH, you know, and the rest of the medical community is aware 
of it?
    Dr. Collins. Well, Congressman, it does sound like a very 
interesting study, and I would hope, yes--the way in which the 
information gets disseminated is exactly what Dr. Patterson is 
getting ready to do, is to publish this in the peer-reviewed 
literature. All of us who are concerned about COVID and 
especially long COVID are avidly reading the journals daily. If 
you could see my desk, you would see a pile of published 
manuscripts that is about 2 feet high that I am kind of 
constantly looking at for what is the new idea. Yes, tell Dr. 
Patterson, if he is listening, send me a preprint. I want to 
see what this is with the cytokine that might be a biomarker 
indicating who is at the greatest risk in something about 
mechanism. That is the kind of thing we are looking for.
    Mr. Doyle. I mentioned that I did introduce Dr. Patterson 
to Dr. Gary Gibbons. We put him in touch with him, and I just 
wanted to draw attention to it because he has been doing a lot 
of good work in this field.
    I got to ask you, my colleague Dr. Joyce I thought brought 
up a great point on, you know, an ounce of prevention being 
worth a pound of cure, and that is some of these therapeutics 
that we can use. Not everyone is going to take this vaccine. We 
know we have people out there that just aren't going to get the 
vaccine, but they may get COVID. And one of the ways to make 
sure they are not long-haulers is to get them some sort of 
therapeutic treatment the minute they get the disease. I have 
heard from a lot of doctors in my district and patients about a 
therapy that is not a novel therapy but one that has been 
around for quite some time and has an excellent safety profile, 
and that is ivermectin.
    What is the NIH and CDC's position on ivermectin? And I 
have a lot of doctors who have contacted me and sent data from 
various randomized control trials showing benefit with this 
drug, and I have been reading that a lot of other countries are 
starting to use ivermectin as a treatment for people that 
aren't vaccinated. Maybe they don't have access to vaccines, 
and it is cheap, and it is safe. So what is the position on 
that?
    Dr. Collins. That is another great question. Yes, there are 
a number of studies on ivermectin. They don't all agree. There 
are certainly people who are very enthusiastic about this, and 
others who are quite skeptical. There is a recent pretty large 
study published in Colombia, South America, where ivermectin 
has been used a lot. It was quite disappointing and didn't show 
benefit for people right after they got diagnosed to keep them 
out of the hospital, but we are really intensely interested.
    We just announced last week a new trial which is called 
ACTIV-6, which means it is the sixth one of this partnership we 
have with industry that is specifically aimed to test oral 
agents that you can give to people right after their test turns 
positive with exactly the goals that you just outlined.
    Ivermectin is a very high-level candidate to get into that 
trial in the very near future. So we are interested in getting 
a really rigorous look at this. Unfortunately, there have been 
other disappointments. We need to really find out exactly what 
the answer is before we begin to advocate for it, but it is a 
potentially promising lead.
    Mr. Doyle. Great. Thank you.
    Madam Chair, thank you so much. I appreciate your 
indulgence.
    Ms. Eshoo. Absolutely, Mr. Doyle. And it is wonderful to 
hear that you are working with my constituent at Stanford.
    And, Dr. Collins, I am worried about what is buried in that 
big pile that you have to read. I hope that you have some 
assistance with that because, if there are real kernels of gold 
in there, we want you to get to them sooner rather than later.
    We have Congresswoman Kathleen Rice. She is the last to 
question this panel, and she has been with us since before we 
gaveled in the hearing this morning. New member of the 
committee, another Member that is value added, and you are 
recognized for 5 minutes. You may be last, but you are not the 
least.
    Miss Rice. Thank you so much, Madam Chairwoman.
    And thank you too for allowing me to waive on for this 
hearing. I would like to thank Dr. Collins and Dr. Brooks for 
all the work that you have done leading our public health 
agencies throughout this pandemic and for your ongoing, 
clearly, your Herculean efforts to understand this disease and 
its long-term effects.
    Dr. Brooks, I have some questions about the MMWR regarding 
the study of long-COVID care that CDC conducted with Kaiser 
Permanente in Georgia. Can you share with us what--and forgive 
me, I had to mute a couple of times so I didn't hear if this 
question was asked, but can you share with us what CDC learned 
from the partnership with Kaiser and what might be some of the 
limitations of the study and what are some of the limitations, 
in general, regarding long-COVID research?
    Dr. Brooks. Thank you so much for that question. Yes, 
actually, no one did actually address exactly that question 
before, so I am really happy to share with you and appreciate 
the opportunity.
    This is a study that CDC conducted with Kaiser Permanente 
Georgia. If folks aren't aware, that is a big HMO here in the 
State of Georgia. The main findings from the study were this: 
Following people who are outpatients only, never admitted to 
the hospital, right--so these were people who probably had 
COVID they could manage outside of the medical care of a 
hospital or an ICU--of these persons, during the 1 month to 6 
months after their COVID diagnosis, about 68 percent sought 
care for some condition.
    Now that alone is sort of a striking figure because imagine 
how many people after a head cold, pneumonia, influenza seek 
additional care a month later. I can tell you from my clinical 
experience, this is quite unusual. So that is a high burden. In 
addition, among all of those people out of that total that 
began, about 38 percent sought care with a specialist that 
might be working on a body system that has been affected by 
COVID. So someone like a cardiologist, a pulmonologist or 
rehabilitation doctor, a doctor who deals with joint pain or 
body pain.
    That was the first important finding. The second was that 
there wasn't a--that it was evenly distributed pretty much 
across different groups. One of the nice things about the 
study, though, is we were able to enroll a pretty hefty number 
of African Americans and Hispanics, representative of their 
prevalence here in the State of Georgia, and that is probably 
because this HMO is one that is accessible to so many of our 
citizens here.
    Some of the limitations here are very important. First, 
when you are using electronic medical records, you are having 
to make a lot of inference about the data that you are finding 
because you are not able to speak to the people that sought 
care or talk to the doctors about, ``Why did I record that 
finding in the paper?'' So understanding the patient's journey 
is something that is not able to be gathered from this kind of 
research, but what it does tell us is that we are seeing 
patterns that are worrisome that a number of--a large number of 
people who, after they recover from outpatient COVID, so not 
needing to be in the hospital, are seeking care, and that is 
not like other infectious diseases of the same kind.
    Miss Rice. Wow. So I think I have time for one more 
question, Dr. Brooks. As the data from the research hospitals 
in your own MMWR seem to suggest a higher prevalence of long 
COVID among women and non-Hispanic/Black individuals who were 
not hospitalized, that group who were never hospitalized for 
COVID. I mean, while it is obviously still early in the total 
understanding of the disease, can you speak to how the data we 
had is informing your guidance to clinicians as well as 
patients?
    Dr. Brooks. Right. One of the first lessons is, when a 
woman tells you she has a problem, listen.
    Miss Rice. That is a novel theory.
    Dr. Brooks. I mean, I know some of the people on this panel 
have probably and in Washington today had the experience of not 
having their complaint taken seriously. It happens to men too, 
it happens to everyone. But I think this is something that we 
need as a clinical and public health community to pay attention 
to.
    Second, it is a little hard for us to disentangle this time 
whether the excess burden, if you will, of what we are calling 
long COVID per that paper is something that is driven by gender 
or race/ethnicity or if it is driven by the inequity in who is 
getting COVID to begin with. And so----
    Miss Rice. Can I ask you, Dr. Brooks, how is the CDC 
ensuring that the research takes into account health equity?
    Dr. Brooks. Right. That is one of the ways we do it is, in 
this study, we can only look at the records of patients who 
sought care. So there wasn't much--what we do in many of our 
other studies, particularly cohort studies where we can control 
sort of who is enrolled, is we try to overenroll 
underrepresented groups to ensure that they are present in 
enough numbers that we can make valid research findings from 
that important population.
    And, in fact, some of our cohort studies now of the eight 
we have running, there is one focused on the Alaskan Natives 
and American Indians. Others are overenrolling African 
Americans and Hispanics, and we look forward to being able to 
continue doing that.
    Miss Rice. Thank you, Doctor.
    And thank you, Madam Chair.
    Ms. Eshoo. The gentlewoman yields back.
    Well, I can't--on behalf of all of the members of the 
subcommittee and the Members that have waived on from the full 
committee, all of our thanks to you, Dr. Collins and Dr. 
Brooks. This has been 3\1/2\ hours of testimony and answering 
questions. I think that we have all learned a great deal from 
you. We also--I think it has deepened and broadened our 
knowledge that we have a long pathway in order to fully address 
long COVID.
    I also want to highlight the intense interest of the 
members of the subcommittee participating in this hearing. We 
have outstanding Members on both sides of the aisle who care 
deeply about this, and this is a nonpartisan issue. So it calls 
for bipartisan approaches. We will continue to work with you. 
We ask you to reach out to us when you see bumps in the road 
where we can assist, but for sure we know, according to the 
statistics, with 32 million infected by the virus and roughly 
10 percent having long COVID, we have a population in the 
country that we need to put our arms around and make sure--and 
make sure--that we bring answers and care to them that is 
designed for exactly what this is.
    So we all thank you very, very much. You are absolutely 
terrific. You are a source of pride to all of us, as more than 
one Member has said, the American people listening in and 
hearing and understanding your extraordinary commitment to the 
people of our country. I can't think of anything that is as 
beautiful as that. So we are lastingly grateful to you. And 
just think, you are finished with us for today.
    So you get to stretch your legs and hopefully have a good 
late lunch.
    Now, we are going to move on to our second panel of 
witnesses, all distinguished--thank you, Dr. Brooks. I am so 
glad that you participated. Thank you, dear Francis.
    Dr. Collins. Thank you so much, Madam Chair.
    Dr. Brooks. Thanks for your attention.
    Ms. Eshoo. Absolutely. Absolutely.
    So now we are going to start with our second panel. The 
first three witnesses that I want to introduce are all long-
COVID patients. So they are not going to get into studies, they 
are going to tell us about their day-to-day experiences.
    First, Natalie--is it ``Ha-KAH-la'' or ``HAH-ka-la''?
    Ms. Hakala. It's ``HAH-ka-la.''
    Ms. Eshoo. Beautiful name. Natalie is a long-COVID patient 
from Eugene, Oregon. She was a collegiate track star, and her 
struggle with long COVID has been covered by HBO's ``Real 
Sports with Bryant Gumbel.''
    Thank you, Natalie, for joining us and making yourself 
available to the committee.
    The next patient, Chimere Smith, she also is a long-COVID 
patient and a consultant for urban communities from Baltimore, 
Maryland. Welcome to you, and thank you for responding to our 
invitation to be a witness today.
    And Ms. Lisa McCorkell, also a long-COVID patient and a 
contributor to the Patient-Led Research Collaborative. Thank 
you to you for accepting our invitation to testify today.
    And two really distinguished physicians. Dr. Jennifer 
Possick, she is the director of the post-COVID recovery program 
at the Winchester Center for Lung Disease at the Yale-New Haven 
Hospital. Welcome to you. And thank you.
    And, last but certainly not least, Dr. Steven Deeks. He is 
the professor of medicine at the University of California, San 
Francisco, one of the great research institutions in our 
Nation, and he is the lead scientist for the Long-term Impact 
of Infection with Novel Coronavirus study, and that is referred 
to as LIINC, I believe. So, welcome to each one of you.
    Ms. Hakala, I am going to call on you first. You are 
recognized for 5 minutes for your testimony. And, again, we are 
very grateful to you and also for your patience, because this 
has been and continues to be a long day, but so worthwhile for 
all of us. So thank you, and you are on.

STATEMENTS OF NATALIE HAKALA, COLLEGIATE MIDDLE-DISTANCE RUNNER 
  AND LONG COVID PATIENT, EUGENE, OR; CHIMERE L. SMITH, LONG 
  COVID PATIENT, BALTIMORE, MD; LISA McCORKELL, TEAM LEAD AND 
 RESEARCHER, PATIENT-LED RESEARCH COLLABORATIVE, OAKLAND, CA; 
  JENNIFER D. POSSICK, M.D., ASSOCIATE PROFESSOR, PULMONARY, 
    CRITICAL CARE AND SLEEP MEDICINE, AND MEDICAL DIRECTOR, 
 WINCHESTER CENTER FOR LUNG DISEASE, YALE-NEW HAVEN HOSPITAL; 
 AND STEVEN DEEKS, M.D., PROFESSOR OF MEDICINE, UNIVERSITY OF 
                   CALIFORNIA, SAN FRANCISCO

                  STATEMENT OF NATALIE HAKALA

    Ms. Hakala. OK. Thank you.
    So, as was stated, I was a collegiate runner at a D2 
College. I got COVID July 4, 2020, and the first 2 weeks were 
very, very mild. I just lost my taste and smell. I had a fever 
for a couple days. My fever broke, and I was feeling, I 
thought, normal immediately following my 2 weeks of quarantine.
    Then, following my 2 weeks of quarantine, I began 
developing chest pain, shortness of breath, difficulty 
breathing. I had to take--I had severe fatigue building up. 
Each week got worse and worse. By the end of July, I discovered 
that I had pneumonia because I went to my primary care 
provider, and it was shown that I had some slight indications 
that it may be pneumonia in my lungs.
    So they put me on an inhaler, some other medications to 
help with that, some as-needed pain medications to help with 
the chest pain I was having. During this time, I was still 
trying to work, only half days. Going into August, I went to 
urgent care once. Everything came back completely normal, so I 
was sent home.
    A couple weeks later, I went back, again, with severe chest 
pain, unable to breathe, could not get comfortable. Went into 
urgent care, and this time my oxygen saturation dropped to low 
80s. You are typically supposed to have 95, so this was 
concerning to them. So they admitted me to the hospital, and I 
stayed there for a few days. They ran a bunch of tests.
    I had a cardiologist look at me, a pulmonologist, an 
internal medicine specialist. I think those were all the 
doctors that looked at me, and most of my tests came back 
completely normal. Nothing was really showing anything 
abnormal, but because my oxygen saturation came back up, they 
sent me home, and they had placed me on a couple of different 
meds to kind of help with pain. And, hopefully, you lower some 
of the inflammation factors that were happening throughout my 
body. They were just assuming what was occurring.
    And the rest of August I did not work. I stayed home on the 
couch completely bedridden. I was unable to make breakfast. My 
big activity for the day was taking a shower.
    Throughout September, it was very, very similar if not 
worse. I would not be able to have a conversation like I am 
right now. I would be stopping every other word to catch my 
breath. And in September is when I got my cardiac MRI, which 
showed inflammation around my heart, and when I was diagnosed 
with pericarditis. I had pleurisy, costochondritis, and just 
overall inflammation they were assuming was happening, 
especially around my chest wall because it was difficult to 
take deep breaths. I started cardiac rehab in October, and that 
was--I was only able to go for like 8 minutes, I believe, on a 
treadmill at a very, very slow pace. I still--I barely started 
watching TV because tracking things on a screen was too 
difficult. It gave me severe headaches, and I was just too 
exhausted.
    By November, I was watching TV again. By December, I was 
able to read a book. I couldn't remember a lot of what happened 
in books. So I had to reread stuff multiple times just to grasp 
what was going on. In January, by the end of January, is when I 
got my vaccine. That first week was very uncomfortable for me. 
I felt like I was back in September, and I did my very first 
jogging in January as well. I jogged for 2 minutes, and that 
was the farthest I could go at a very slow pace.
    Then in February is when I got my second dose of my 
vaccine. Same reaction as the first one, a whole week of 
discomfort, difficulty breathing again, increased chest pains, 
more headaches, more fatigue. And I was still very 
uncomfortable following that. About 2 weeks after my vaccine is 
when I started to notice that I felt like I was going back to 
how I was in mid-January, and I was able to start jogging again 
in February. I actually started help coaching. So I am coaching 
a track and field team. So I am able to stand for a couple 
hours a day now, and currently I am able to jog for 15 minutes 
is the most I can go at like about a 10-minute-mile pace, which 
compared to my previous self, I would normally run an easy run 
at 8-minute pace. So I am still a little ways off, but 
definitely improving.
    My energy has improved a little bit. I am definitely able 
to focus for a lot longer amounts of time now, but I am still 
unable to work my full job that I previously was working before 
I got sick. So that is kind of where I am at now, and I think 
that is everything.
    [The prepared statement of Ms. Hakalah follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Well, thank you very much. That is quite a 
journey from the Fourth of July in 2020 you said----
    Ms. Hakala. Yes.
    Ms. Eshoo [continuing]. To the present. Thank you very, 
very much. We appreciate your testimony.
    The Chair now recognizes Ms. Smith. You are recognized for 
5 minutes. And you may begin. Welcome and thank you, again, for 
accepting our invitation to testify.
    You need to unmute.
    You need to unmute.
    Ms. Smith. Thank you.
    Ms. Eshoo. There you go. You are recognized. Thank you. 
Glad you unmuted. We need to hear you.

                 STATEMENT OF CHIMERE L. SMITH

    Ms. Smith. Thank you so much for the opportunity to speak. 
I am sorry. I am getting my screen together. I apologize. Thank 
you.
    I asked myself if I was nervous about being here, and I 
thought to myself that if I could spend 5 days a week for 5 
years teaching brilliant, temperamental middle school students 
in Baltimore, I could do anything.
    I know that you are a tough crowd, but those students made 
me even tougher.
    I want to make it clear that I am no different than most of 
the people you know with long COVID, but there is a 
distinction. I am a Black--I am Black living with long COVID. I 
am a Black woman living with long COVID. You may not be able to 
tell, but I am a Black disabled woman living with long COVID, 
and I am now a poor, Black, disabled woman living with long 
COVID. Saying it aloud makes it no more easier to accept.
    Long COVID is not just a White woman's condition no matter 
the picture our media tries to paint initially. I am not alone. 
Before we knew long COVID existed, there were many Black women 
who suffered with chronic conditions that went ignored or 
misdiagnosed. I don't know where these women are today because 
they have been shunned from medicine and forced into silence.
    I was not raised to tell my personal business. Like many 
people, I was taught to be seen and not heard, that what goes 
on in my house stays in my house. Yet had I lived by those 
deeply imbedded mantras, I would not be sitting here before you 
today.
    I knew who I spoke for when I shared these experiences with 
the NIH, and I know why I am here today. I am among Black women 
who are now unemployed, homeless, and depressed with broken 
bodies. Over the last year, Black women lost more jobs than any 
other race. That means our medical bills, rent, and utilities 
while struggling with this condition have been neglected.
    If I did not have a loving family, I would be speaking to 
you today from my car, the only property I now own. Our 
circumstances may not seem different than others, but what 
diverges our path is we were already disadvantaged and abused 
by medicine, science, and government.
    I was already poor during my childhood. I taught students 
in the 'hood who were already receiving inadequate and 
substandard healthcare. We have already been where COVID is 
threatening to take people with privilege, power, and status. 
We are not new to this. Sadly, we are true to this. We have 
just been waiting and hoping for compassionate doctors and 
politicians who would acknowledge us.
    Long COVID is another weight to what Black people have 
already been carrying. It just has another name. If you are 
wondering why Black people won't speak out, they fear they may 
end up like me. I lost my vision for 5 months because doctors 
ignored my dense cataract from COVID and called it a dry eye. 
They may end up with false negative tests, being gaslit into 
believing they never had COVID or like Leiah Jones from 
Charlotte, North Carolina, who wrote her own obituary before 
dying from long-COVID complications.
    No one wants to hear that long COVID has decimated my life 
or the lives of other Black women. In less than a year, it has 
made me forgetful, unreliable, unemployed, nervous, with severe 
body aches and pains. It has destroyed our brains, the most 
beautiful parts of us.
    I was an excellent teacher. Now, I wouldn't trust my memory 
or brain function with any child right now. Would you? However, 
I am proud of how relentless and angry I became to save my own 
life, and we are in desperate need of money, swift, sufficient 
disability policies and benefits, comprehensive educational and 
employment guidance that recognizes our condition, and 
accommodations that welcome us into research studies without 
conventional restrictions.
    It is imperative that we create equitable research 
standards and practices to capture current and innovative data 
that focuses on Black people with long COVID. I was recently 
rejected three times for an important NIH study. That alone is 
a travesty. There are currently no studies reported that 
specifically focus on Black people with long COVID. Also, as 
there is a growing evidence of the direct connection between ME 
and CSF in long COVID, we must reconcile that there are 
millions of Black people who have already disappeared from our 
society. We should be funding studies that find and treat ME 
patients.
    We need medical care that reflects equitable, cost-
effective, safe, and timely education and treatment. We have 
recently learned from the CDC that Black people venture to 
their doctors for care up to 6 months after their acute COVID 
illness. This information is extremely telling because 
historically we know that Black people don't like to go to the 
doctor's. But now spending the last year as a poor, Black, 
disabled woman with long COVID, I no longer need to wonder why.
    Post-COVID clinics cannot do this work alone in urban 
communities. I am working to create a hub for Black long-COVID 
patients using my church building to provide free mental health 
and other medical resources to support patients, their 
families, and caretakers, but I need funding opportunities to 
continue doing this work.
    I am a poor, Black, disabled woman living with long COVID 
trying to make and be the difference.
    Thank you.
    [The prepared statement of Ms. Smith follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you very much, Ms. Smith, for your really 
compelling testimony.
    The Chair now recognizes Ms. McCorkell for 5 minutes for 
your testimony, and, again, we all thank you for accepting our 
invitation to be a witness today. You probably didn't realize 
that you were signing up for an entire day, but all of our 
thanks.
    You are now recognized.

                  STATEMENT OF LISA McCORKELL

    Ms. McCorkell. Good afternoon, Chairwoman Eshoo, Ranking 
Member Guthrie, and members of the subcommittee. I appreciate 
the opportunity to speak to the long-COVID experience and to 
shed light on the barriers that patients face that you have the 
power to do something about. I am testifying today as a long-
COVID patient and as a member of the leadership team of the 
Patient-Led Research Collaborative, a group of long-COVID 
patients with backgrounds in research, policy, and data 
analysis who were the first to conduct research on long COVID.
    My symptoms began on March 14, 2020. Like many of what we 
call first-wavers, I was not afforded a COVID test because at 
the time tests were limited to hospitalized patients and those 
with shortness of breath, cough, and fever, the last of which I 
didn't have. I was told by a doctor to isolate and, within 2 
weeks, I would be recovered.
    A month later, I was in worse health than in that initial 
stage. I couldn't walk more than 20 seconds without having 
trouble breathing, my heart racing, and being unable to get out 
of bed the rest of the day. My story is not unique, and this 
was evident when I joined the Body Politic support group last 
April and saw thousands of people who were also experiencing 
prolonged symptoms. Patient-Led Research Collaborative was 
born, and we conducted a survey of 640 patients documenting 
these symptoms and experiences. The result was the first study 
on long COVID and the first to document numerous neurological 
symptoms and extensive multiorgan impact of the illness. It was 
clear then, 1 year ago, that the death/recovery binary that 
COVID has been framed to be is simply not true.
    Our research helped raise awareness of the illness and got 
the attention of CDC, NIH, and WHO. Our most recent survey 
asked about 205 symptoms over 7 months and received almost 
7,000 responses. In our recent paper, 92 percent of respondents 
were not hospitalized but still experienced symptoms in 9 out 
of 10 organ systems on average. We found that patients in their 
seventh month of illness still experienced 14 symptoms on 
average. The most commonly reported were fatigue, post-
exertional malaise, and cognitive dysfunction.
    In fact, 88 percent experienced cognitive dysfunction and 
memory loss, impacting their ability to work, communicate, and 
drive. We found that this was as likely in 18-to-29-year-olds 
as those over 60. Lesser-known symptoms include tremors, 
reproductive changes, months-long fevers, and vertigo.
    Over two-thirds require a reduced work schedule or cannot 
work at all due to their health condition; 86 percent 
experience relapses where exerting themselves physically or 
mentally can result in a host of symptoms returning. Long COVID 
is complex, debilitating, and terrifying. But patients aren't 
just dealing with their symptoms. They are dealing with 
barriers to care, financial stability, and recovery. Due to the 
lack of a positive COVID test alone, patients are being denied 
access to post-COVID clinics, referral to specialists, health 
insurance coverage, COVID-related paid leave, worker's comp, 
disability benefits, workplace accommodations, and 
participation in research.
    When we know that not everyone had access to COVID testing, 
that PCR test had a false and negative rate of 20 to 40 
percent, that antibody tests are more accurate on men and 
people over 40, and that multiple studies have shown that there 
is no difference in symptoms between those with a positive test 
and those without, why are we preventing people who are dealing 
with real symptoms from accessing what they need to survive?
    Even with a positive test, patients are still being denied 
benefits or have to wait months until they kick in. Medical 
bills are piling up. People are being forced to choose between 
providing for themselves and their family and doing what is 
best for their body. The toll that having inadequate paid 
leave, workplace protections, and benefits will take on our 
economic and healthcare systems over the next several decades 
is of a magnitude like we haven't seen before.
    As COVID continues, more and more people are developing 
long COVID. Waiting lists for post-COVID clinics keep getting 
longer, and yet many clinicians continue to gaslight us and 
tell us that our symptoms are in our head. This is particularly 
true for people of color, women, and the LGBTQ community. I am 
both privileged in my financial stability and lucky that people 
with ME advised me early on to pace, which allowed me to 
continue working.
    But I want to mention something. Those stimulus checks that 
you all provided us to get through the pandemic--I do really 
appreciate them, but every cent of mine was spent on urgent 
care and doctor's visits where I was repeatedly told that my 
tachycardia, my inability to exercise, and brain fog was caused 
by anxiety, and there was no way that I could have had COVID 
since I didn't have a positive test.
    Post-viral illnesses are not new. The cracks in our system 
that long COVID has exposed are not new. It is just that now 
more people are paying attention. We are counting on you, 
members of the committee, to use the power your constituents 
gave you to address these issues head on, to listen to you and 
work alongside the disabled and chronically ill community to 
prevent more people from becoming ill.
    I understand these are big challenges and big topics to 
address, but at this point there is no other option. Thank you 
so much for inviting me to speak to you today, and I look 
forward to answering your questions.
    [The prepared statement of Ms. McCorkell follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you so much, Ms. McCorkell, and that is 
exactly why we called you as witnesses today. So thank you 
very, very much.
    I now would like to recognize Dr. Possick. Thank you for 
your patience in waiting, and we feel very honored that you 
would join us, and you are recognized for your 5 minutes of 
testimony.

             STATEMENT OF JENNIFER D. POSSICK, M.D.

    Dr. Possick. Thank you, Chairwoman Eshoo, Ranking Member 
Guthrie, and members of this committee. And thank you, too, to 
my fellow panelists whose company it is humbling to be within. 
I hope to share my perspective as a pulmonologist caring for 
people with post-COVID disease, including long COVID.
    So in Connecticut the surge initially arrived in March of 
2020. And within weeks thereafter, people were reaching out to 
us about patients who remained profoundly short of breath after 
their acute illness had passed. My colleagues and I were struck 
by how difficult it was to tell the difference between people 
recovering from mild acute COVID and those who had required 
ICU-level care. Both groups had the physical, cognitive, and 
psychological fallout we would expect from a critical illness 
or a prolonged intubation. And in addition to being short of 
breath, they reported a host of other symptoms.
    I saw a teacher who had recurrent bouts of crushing chest 
pain mimicking a heart attack, a young mother who would have 
racing heartbeat and dizziness every time she played with her 
toddler, a local business owner who couldn't remember the names 
of his long-term customers or balance his books, and a home 
health aide who didn't have the stamina or strength to assist 
her elderly clients.
    We assembled a team of pulmonologists, physical therapists, 
and a social worker to provide a comprehensive evaluation in a 
single clinic visit. A broader coalition with physicians in 
cardiology, neurology, and psychiatry, all with COVID-19 
experience, worked together to untangle complex symptoms.
    We have spent this year learning alongside our patients, 
about half of whom were never hospitalized. They are mostly 
working age, previously high functioning. Many were frontline 
or essential workers. Many were initially disbelieved.
    Their quality of life has been seriously impacted. Some 
can't walk to the mailbox or remember a shopping list, much 
less resume their everyday lives and work. They have used up 
their paid sick leave, they have cut back their hours, they 
have left or lost jobs. They have difficulty accessing 
workmen's compensation benefits and FMLA or securing workplace 
accommodations. Some have even cut back on food, rent, or 
utilities to pay for mounting medical expenses.
    As was seen in SARS and MERS, we do have some patients with 
persistent lung disease, but routine testing is frequently 
unrevealing for these patients and requires more detailed 
evaluation to investigate symptoms that span multiple organ 
systems.
    Some of our patients have completely recovered with time. 
Others have made progress but continue to experience 
debilitating symptoms.
    Consensus practice supports many forms of rehabilitation 
services, but insurance approval and coverage have been beyond 
challenging, and demand outpaces availability in any case. For 
patients with ongoing oxygen needs, requests for portable 
oxygen concentrators can be delayed or even denied, 
complicating physical recovery and mobility.
    We are a well-resourced program at an academic medical 
center, but we are swamped by the need in our community. This 
year, we have seen more patients with post-COVID-19 conditions 
in our clinic alone than we have of new cases of asthma and 
COPD combined.
    Looking ahead, the magnitude of the challenge is daunting. 
There are over 31 million survivors of acute COVID-19 in the 
United States. And we don't know how many people will be 
affected, what kind of care they will need, or how long--what 
kind of care that will entail, or how long they will need it.
    Research will ultimately help us to understand the origin 
of these symptoms and to identify effective treatment. But in 
the meantime, their care cannot wait.
    First, we must increase public awareness of post-COVID-19 
disease, highlighting that it can occur after mild acute 
illness in young individuals and in those without preexisting 
comorbidities.
    Second, we must ensure early and equitable access to care 
for individuals with post-COVID-19 conditions, which cannot 
practically be confined to specialty centers. Patients need 
access, not only for evaluation but also to services like 
pulmonary rehab, neurocognitive rehab, and mental health 
services. Moreover, clinicians must be liberated from prior 
authorization and appeals processes so that we can focus on the 
care of our patients.
    Finally, we must address the socioeconomic consequences of 
post-COVID disease on working people, including the impacts on 
their livelihood and health insurance access. We must recognize 
that this condition, including occupational acquired infection, 
has prevented many from returning to work despite their desire 
to do so, and must ensure access to services and benefits.
    We have made great strides and accomplished a great deal in 
this unprecedented year, but as we move into the next phase of 
response we must realize that we are pacing for a marathon 
rather than a sprint.
    I thank you again for the opportunity to take part in this 
important discussion.
    [The prepared statement of Dr. Possick follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you very much, Dr. Possick.
    There is so much to absorb from our hearing today, but I 
think that every Member is hanging on each word that is uttered 
by our witnesses. So all of our thanks to you.
    Dr. Deeks. A colleague said, I said Dr. Deeks is the lead 
scientist for the long-term impact of infection with the novel 
coronavirus study. So, Dr. Deeks, thank you, and welcome to our 
subcommittee. And you are recognized for your time to give 
testimony to us.

                STATEMENT OF STEVEN DEEKS, M.D.

    Dr. Deeks. Thank you. It is tough to go last. Much of what 
I was going to say has been said, so I will go through this 
quickly.
    I want to talk about three things that are sort of known 
scientifically and four or five things that are not known and 
are key to sort of figure out just to provide a platform for 
the questions, right?
    So in terms of what is known, the syndrome is real, OK? And 
that is, as our three first speakers sort of outlined, there is 
a lot of stigma associated with this syndrome. And external 
validation from NIH, from medical societies, from Congress that 
this is a real problem, to me, is going to be very therapeutic 
and hopefully reduce a lot of stigma around this. And so that 
is great. There is not universal consensus, though, so there 
are some skeptics out there. I will talk about that in a 
second.
    Second, there are many different flavors, many different 
spectrums, phenotypes we call them in medicine, in terms of 
what is going on with COVID. And I think this is very 
important, because I think they are going to end up having 
different mechanisms.
    The vaccine story, right, so we heard these stories about 
how vaccines make people better, and that is possibly because 
the virus is persisting in certain people and the vaccine makes 
the immune system stronger and the virus goes away. Our 
experience in our cohort is that the vaccines actually make 
some people worse. And we think it is because the vaccine is 
enhancing inflammation.
    So I think, you know, there are three or four different 
pathways here that are at play with different syndromes. And so 
it is not--I don't think it is long COVID. We are going to have 
to basically slice and dice this, figure out the clinical 
phenotypes, figure out the mechanisms, and then figure out the 
therapies.
    Third thing that is known is that symptomatic post-COVID is 
common: 20, 30, 40, 50 percent of people have symptoms 4 to 12 
weeks. Disabling disease, like we heard from the three stories 
today, fortunately is not that common, but it exists and is 
probably the thing that we need to focus in on in terms of, I 
think, digging up mechanisms and therapies. So that is what is 
known.
    What is not known. First, we don't have a way of measuring 
this, right? Everyone who has got a cohort or a clinic measures 
it differently, they report stuff differently. As a 
consequence, the epidemiology is a mess, right? We don't really 
have a good sense of what is going on. We need--and this has 
been said before--general consensus on how to define the 
syndrome, how to measure it in studies so that we can all 
basically be saying the same thing.
    Second, we--and this is really to the first--we don't 
really know the prevalence of either the minimally symptomatic 
stuff or the very symptomatic stuff. And we don't really know 
its natural history. And these things are actually stuff that, 
hopefully, we are going to play out.
    We do have a sense of who is at risk, right? And I think 
there are a couple issues here. People who are very sick early 
on are high risk, but asymptomatic people get it. Women--in 
almost every cohort, women are more likely to get this than the 
men. And this, to me, is probably the strongest hint that we 
have in terms of the biology, because women, in general, are 
more susceptible to many autoimmune diseases, and we know why. 
And so paying attention to that fact of why it is more common 
in women, I think, is providing very important insights into 
the mechanism and is directing how we are going about our 
science to identify therapies.
    Third--and this is an important issue we haven't really 
talked about. It is very complicated, and it is why there are 
some skeptics out there. At the same time people are getting 
acute COVID, they are living in a society that is broken. There 
is lots of social isolation, there is lots of depression, there 
is lots of people struggling who did not have COVID. And the 
way in which these have--the way this social economic 
environment that we are living in has interacted with this 
acute infection is likely contributing to what is happening in 
ways that are very important but I think ultimately are going 
to be hard to untangle and something that has not been 
discussed.
    Fourth, we don't know the mechanism, but fortunately the 
NIH is on it. And this is what the NIH does very well, right? 
Go back to the history of HIV. They figured out very quickly 
what the mechanism was of HIV. And once that happened, industry 
got involved. And once that happened, we had 20, 25 drugs for 
HIV. And so we need the mechanism. So what NIH will do, and 
then once that happens, we will get industry involved.
    And that leads to sort of the last two things, right? We 
need more engagement from industry. Academics are not going to 
fix this. We are going to describe the natural history, we are 
going to figure out the mechanism, but we are not really good 
at doing the drug development. And so we need to de-risk what 
is happening in terms of industry. When you give them a 
mechanism, we need to have the FDA and other people involved 
saying, ``This is a disease, this is a syndrome that you can 
treat. And if you do so, we will give you [inaudible] drug 
indication.''
    And finally, as illustrated by today's discussion so far, 
we need at the table industry, regulatory, academic, we need 
representatives from all affected communities, because every 
voice counts. And how people are experiencing this very much 
depends on where they are coming from.
    Thank you.
    [The prepared statement of Dr. Deeks follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you, very, very much, Doctor. It is really 
compelling testimony.
    Where do I start? I am going to recognize myself for 5 
minutes of questions.
    To Dr. Possick, on the issue of the multidisciplinary team 
of specialists that were formed at the clinic, I always look 
for what we already have established in our country that we 
could make use of, such as, you know, the federally qualified, 
you know, community health centers across our country. We have 
made some very heavy investments through all the legislation 
that we passed last year and I believe again in the American 
Rescue Act.
    In your view, can these be--you know, what we have in 
clinics that are attached to academic institutions, but we 
don't have that in every community in rural areas in the 
country and we are not going to, especially moving through 
this. Can that team, do you think, be replicated and stood up 
through the community health clinics in our country?
    Dr. Possick. Thank you for that question. I think it is a 
really important one. I think it is important to acknowledge 
too that the different kinds of post-COVID clinics that have 
stood up around the country are all really different from one 
another, and they are very much grassroots efforts. Whoever had 
the resources, had the time, was able to take the initiative 
and forge the relationships, because most of them are 
multidisciplinary.
    Ms. Eshoo. How many are there, do you know?
    Dr. Possick. Over 60.
    Ms. Eshoo. Ah.
    Dr. Possick. Yes. So, you know, I think that it was 
necessary to engage subspecialists to aggregate information 
quickly and aggregate experience, but now is the time to bring 
that back out into primary care and, particularly, community 
organizations and federally qualified health centers, because I 
think that the shear math of the potential problem will make it 
essential that we do so and also not to leave any community 
behind.
    Ms. Eshoo. Well, obviously, that is always our goal, our 
North Star. Because, boy, going back and trying to repair the 
holes in the safety net is really an ordeal, and a lot of 
people are hurt as a result of it.
    I want to go to Dr.--what is the matter with me? Fog. Dr. 
Deeks, are you aware of the study that is coming out of Texas 
relative to this whole issue that COVID-19 alters human genes 
and explaining the mystery behind the coronavirus long-haulers? 
Are you familiar with that? And if you are, can you elaborate 
on what is part of that?
    Dr. Deeks. I am afraid I am not familiar with [inaudible] 
study that you are talking about specifically.
    Ms. Eshoo. OK.
    Dr. Deeks. Virus infections and inflammation do affect the 
methylation, and I am assuming that is what we are talking 
about here, but I cannot honestly provide anything beyond that.
    Ms. Eshoo. OK. Well, specifically, the scientists reveal 
that the spike protein of SARS-CoV-2, the virus causing COVID-
19, creates long-lasting changes to human gene expression and 
that these tiny spikes cover, you know, much of that. But maybe 
you can research this a little bit and give me a written answer 
to it, because I am very curious about it.
    To Ms. Hakala and Ms. Smith, you have--if there is anything 
you have driven home to members of the committee, is that you 
have not been listened to. You have not been listened to. So 
today, obviously, it is your chance to be heard. What do you 
think is the most important thing that you want Congress to 
understand about long COVID? And why don't we start with Ms. 
Smith and then go to Natalie.
    Ms. Smith. Thank you for asking that. I appreciate that 
question. It has been so important to me, because I am a Black 
woman who understands that, historically, Black women have not 
been believed for so many different chronic conditions. It has 
been important for me to drive home how important it is to 
invest in equitable research and treatment and healthcare for 
other Black women who are suffering with long COVID.
    Many of us are afraid to speak out because, historically, 
we understand that we have not been believed. We have not been 
taken seriously. Some of my friends that I have met, my new 
friends, my wonderful friends that I have met that have long 
COVID now have mentioned to me--we share stories of being 
racially profiled and discriminated the several times we have 
gone to hospitals and medical centers for treatment, and that 
is devastating.
    So it is important for me to assure that Black people who 
live in urban communities, underserved communities, low-income 
communities where I have taught, where I have lived, and where 
I have served for the past 5 and 19 years, that we receive 
education and care that is comprehensive to us. We have not 
received that yet. We have not received that yet. And there are 
no studies that speak to that. So thank you for asking that 
question.
    Ms. Eshoo. Well, thank you for your answer. With all the 
passion in the world, you are teaching us. You are.
    Ms. Smith. Thank you.
    Ms. Eshoo. Anybody who doesn't start paying attention to 
you, you tell them that you were a witness in the Congress of 
the United States.
    Ms. Smith. I will.
    Ms. Eshoo. Start with that one. And if they don't believe 
you, have them call me.
    Ms. Smith. Thank you. I will.
    Ms. Eshoo. Natalie and Lisa, do you want to add something 
to that?
    I know I am over the time, but I think that, you know what, 
we are spending--this is important time. Do you want to add 
something to that that Congress needs to know?
    Ms. Hakala. Yes. I want just say that, like she mentioned, 
really making sure there is enough research. And like just 
getting the word out to people that this is a recurring problem 
for a lot of people in a lot of communities. And it is 
primarily like frontline people and people who are not 
protected initially and then weren't believed after they were, 
like, serving all these other people. And they weren't believed 
when they were told, ``You are having these problems.''
    I was in the hospital and some of the doctors didn't even 
want to come into the room and listen to my heart, because they 
were--I don't know if they were afraid that I was going to get 
them sick, even though I was past my 2 weeks of initial 
infection, so I was no longer contagious, but they still did 
not want to come in and treat me. They were afraid that--I 
don't know if I would get them sick or what they were afraid 
of. But it is very disheartening to not want to be heard. And 
it is, like, really appreciative that you guys are listening to 
us and wanting to help those people who weren't listened to for 
so long.
    Ms. Eshoo. Lisa, do you want to add something to that?
    Ms. McCorkell. Yes. Thank you for the opportunity. I would 
say, to echo Chimere and Natalie, I think including making sure 
that there is equitable access to care and to research is one 
of the most important things. It needs to be affordable care as 
well. We are not really seeing that.
    And then also, people need the ability to and the knowledge 
to rest. That is one of the most important things that people 
can do, particularly at the beginning of their illness. There 
is research that shows that people who rest in the beginning 
stages of their illness are less likely to have prolonged 
symptoms at month six. But people don't have the ability to do 
that financially. And that is a problem with our paid sick 
leave, with our disability benefits, with worker's 
compensation. So we really need to make progress with workplace 
accommodation and our safety net in order to really help long-
haulers.
    Ms. Eshoo. Well, I think that what each one of you said is 
enormously helpful to all of the Members. And I thank the 
Members for their patience in the Chair going way over her 
time.
    I now yield to the ranking member of our subcommittee, Mr. 
Guthrie of Kentucky, for your time to question.
    Mr. Guthrie. Thanks, Madam Chair. And I am going to try to 
stay within my 5, but if one of my colleagues wants a little 
extra time, maybe we can be indulgent as well.
    Ms. Eshoo. I have been very generous with everyone, so----
    Mr. Guthrie. I know. Exactly, exactly, as we move forward.
    I just have--well, with all the questions I have had, you 
guys have talked about it. And, one, Ms. Smith, we had hearings 
on maternity and different disparities between people of 
different ethnic backgrounds, and healthcare results is 
something that this committee has looked at from, not just in 
this respect, but a lot of others and holds serious and wants 
to get to the bottom of and move forward.
    The thing is I think all three of you said that you were 
either underdiagnosed or misdiagnosed or not diagnosed, or I am 
not sure moving forward. And it seems like Dr. Deeks kind of 
had maybe one of the best explanations that it sounds like, in 
your profession, you guys are trying to figure this out as 
well. But it does seem--I think to quote, you said it is a 
mess. That is what you said in your testimony.
    But it does seem that people are presenting with some 
issues, whether the physicians or the healthcare providers seem 
to think that it is long COVID or some other issues. It just 
seems like they are getting dismissed.
    And, Dr. Possick, I spent a couple of years in the Yale New 
Haven area. I have a lot of--very impressed with the Yale New 
Haven Hospital there. And I think you also said that you have 
more people presenting for COVID long haul than asthma or COPD 
combined.
    And so, why do you think that people are coming--to the two 
physicians here, why do you think people are coming to the 
hospital and having the type of experience they are having when 
they really do have some kind of illness? I know it is 
difficult to diagnose and it is also new, so we are trying to 
figure it out, as Dr. Deeks said, trying to sort through it. 
But could you just give us some insight why you think your 
colleagues in the healthcare world are dismissing people as not 
being sick when they are? Dr. Possick, do you want to go first?
    Dr. Possick. Sure. Well, first of all, I think implicit 
bias and cognitive bias are not issues that are new. But, as 
one of the members pointed out in the first panel, it has sort 
of thrown all these things into sharp relief, and we have had 
to face them. But I think one of the particular challenges with 
post-COVID conditions is that it is new and physicians don't 
necessarily even know what to be looking for. I think some of 
us are still not entirely convinced that this is all a single 
entity, you know, and we are all just putting our hands on 
different parts of the elephant. It may be that with time we 
come to recognize, as Dr. Deeks says, that there are multiple 
phenotypes. But I think our implicit biases have gotten in the 
way at multiple points during this pandemic, and we need to 
take steps to rectify that.
    Mr. Guthrie. Are you collaborating with other 
pulmonologists? Are you seeing--I mean, how are you guys 
sharing this? Because that is what we are trying to--I am 
trying to figure out. I am not speaking for all of us. But how 
does this get disseminated as we are learning, as we go, since 
it is so new?
    Dr. Possick. The CDC has been incredibly helpful in this 
regard. You know, the COCA calls have been essential. They 
brought all of us to the table together to talk about our first 
impressions, a general consensus, helping to simply name it. 
Naming has power, and we need to do that sooner rather than 
later and come up with clinical criteria so that primary care 
physicians can feel empowered to codify a diagnosis for a 
patient where maybe without guidance they don't feel 
comfortable doing so.
    Mr. Guthrie. OK. Thanks.
    Dr. Deeks, kind of my line of questions, if you have some 
comments on that as well.
    I think you are muted.
    Dr. Deeks. I can't believe I did that.
    There are two things I would say. Clinicians like to be 
able to measure stuff, right? They like--they want to measure 
something and then they want to give a drug, right? That is 
what we as physicians do. We want to test, right? So--and there 
does not exist one for this problem, because the symptoms are 
very difficult to quantify, and they are somewhat vague and 
they vary from person to person.
    There is, within this whole long COVID, a subset of people 
who have tachycardia. And even--like me, I gravitate to that, 
because that is measurable, right? People stand up, they have 
fast heart rate. That is a diagnostic test. That is another 
spectrum within this whole COVID. And I particularly, you know, 
engage more in that because I can measure it and we can treat 
it. There is treatment for that one. And so it is a cultural 
thing, right? That is what physicians do. We want to be able to 
say, here is the test and here is the treatment. And right now, 
we have no test and we have no treatment, and this is the 
fundamental problem.
    Another issue, which I did mention, is a lot of clinicians 
think, well, you know, we are all depressed. It has been a 
lousy year. You know, let me tell you about my problems. And I 
will tell you, I have colleagues at work who say, ``I don't 
believe why you are studying this phenomenon,'' right? Because 
if I have the same problem and I never had COVID, it is because 
of the pandemic. And so these are the kind of discussions that 
are happening in the clinic. And this is what people who have 
[inaudible] are confronting this kind of culture, which will be 
difficult to overcome.
    Ms. Eshoo. It is his connection.
    Mr. Guthrie. Well, thanks, thanks.
    And that is why we are having this hearing, so that is just 
helpful. Thanks.
    And I did overspend my time. And I will yield back, Madam 
Chair.
    Ms. Eshoo. Well, you are most welcome, Mr. Guthrie, and 
thank you.
    The Chair is pleased to recognize the gentlewoman from 
California, Ms. Matsui, for her 5 minutes of questions.
    Ms. Matsui. Thank you very much, Madam Chair.
    And I want to thank the second panel for sharing your 
stories and your experiences with us today. That gives us a 
sense of how people who have had this COVID-19 long haul have 
experienced all of this. And we are just beginning to 
understand what long COVID looks like, and your voices are key 
to helping us determine where to go from here.
    Now, we know that the COVID-19 pandemic and the resulting 
economic recession have negatively affected many people's 
mental health. Increased stressors such as job loss and 
financial insecurity, as well as the physical distancing 
necessary to slow the spread of the virus are difficult enough. 
But patients with long COVID face the added challenges in 
managing physical and mental symptoms of a new chronic illness. 
Furthermore, patients with long COVID are often first referred 
to healthcare professionals specializing in respiratory or 
rehabilitation medicine.
    Dr. Possick, as you reopened face-to-face outpatient 
services, what strategies did your pulmonary practice take to 
meet the multifaceted needs of patients presenting with post-
COVID-19 symptoms?
    Dr. Possick. Thank you for that question. So we had very 
deliberately created both an in-clinic and a beyond-clinic 
model that was multidisciplinary, because we could tell, even 
with the patients we met earliest via telehealth alone, that it 
was not purely a respiratory issue. And we know that too from 
post-ICU syndrome that it is multidimensional, really needs a 
multidimensional approach.
    We were lucky that we were able to assemble other 
stakeholders in respiratory therapy, physical therapy, and in 
other medical specialties to tack that on. But probably one of 
the most important things we did is we built a collaboration 
between our social worker and psychiatry services, which has 
really been instrumental in helping support patients while we 
work through the medical issues.
    Ms. Matsui. That is wonderful.
    Let's see. Lisa, I appreciate your testimony on integrated 
medical care that is needed to treat long COVID. Can you 
elaborate how mental health treatment fits in with that 
approach?
    Ms. McCorkell. Yes, absolutely. Thank you for the question. 
I think with long-COVID patients, and I think, like Dr. Deeks 
said earlier, you know, there is--we are all going through a 
lot right now, and particularly with long COVID, there is a lot 
that needs to be treated but as a secondary treatment. And what 
is happening with a lot of long-COVID patients is that, like 
what happened with me, anxiety is being treated as a primary 
treatment. And just because we may present with anxiety doesn't 
mean that is causing our symptoms. I think that is really 
important for a clinician to understand. We are dealing with 
having a new chronic illness, newly becoming disabled, as well 
as just living during a pandemic.
    And I think in terms of an integrated care, it is really 
important that in any kind of post-COVID clinic or any kind of 
clinician setting, that the mental health treatment is 
available and is recommended for folks, but, again, as a 
secondary treatment.
    And I did want to mention just something in regards to 
post-COVID clinics. I think a lot of them have provided a lot 
of really great care, but currently there is no Medicare 
reimbursement strategy that is happening. And that is something 
that really needs to be prioritized, because, without that, it 
is really inaccessible and inequitable.
    Ms. Matsui. OK. Well, thank you, Lisa.
    Dr. Deeks, you made the salient point that untangling 
symptoms related to infection versus other issues will be 
difficult when it comes to treating long COVID. Do you agree 
that integrated care is the best approach here?
    Dr. Deeks. I worked--before 2020, I did full-time HIV care. 
And HIV care, since the late '80s, has been one in which we 
integrate all aspects of care in the same clinic, and it works. 
And a really important part of the care that we provide in the 
public health clinic is access to social workers and people who 
have expertise in sort of working through all the issues with 
insurance and so forth.
    So, yes, we need integrated care with physicians, physical 
therapists, psychiatrists, and I actually think a lot of social 
workers and people who can do patient support groups. And that 
is what these clinics would do and provide people with access 
to all this stuff. But it is navigating these complicated 
economic issues that is really, really difficult. And that 
needs to be part of the clinic. And I think the three stories 
we heard today sort of made that point.
    Ms. Matsui. Absolutely. Thank you very much, Dr. Deeks.
    And I yield back. Thank you, Madam Chair.
    Ms. Eshoo. The gentlewoman yields back.
    Pleasure to recognize the ranking member of the full 
committee, Ms. Cathy McMorris Rodgers, for her 5 minutes of 
questions.
    Mrs. Rodgers. Thank you, Madam Chair.
    Ms. Smith, you say that we must reconcile our unwillingness 
to recognize chronic conditions we can't visibly see. What do 
you believe can be done to educate health providers and 
patients about long COVID?
    And in your testimony, you discuss using your church as a 
hub for patients and their caregivers to receive long COVID 
education and mental health treatment in Baltimore. Would you 
describe that project in more detail?
    Ms. Smith. Sure. You know, I am in the planning process and 
in the grant-writing process of that proposal, hoping that I 
can get some funding from somewhere so that I can make that a 
reality. And I think that is important.
    Both questions that you ask tie in together. I am talking 
to the post-COVID clinic at Johns Hopkins, which I did not 
qualify for, sadly, because I have never tested positive for 
COVID. But one of the doctors there--who I can't recall, 
because I have brain fog, and memory loss, and I am excited--
she and I will be working together to try to find a way, a safe 
way, a protective way to reach some of those patients who need 
additional support outside of that care clinic.
    And so it is my hope that the proposal that I write will 
explore a safe way, you know, for the residents of the 
northwestern Baltimore community to come to a place where they 
can receive mental health treatment or counseling sessions, to 
receive any additional medical education that we can provide 
for them and their families. It is so important, because I had 
to travel to Washington, DC, to get--to be even qualified for a 
post-COVID clinic appointment. And so people like me who live 
in a low-income neighborhood should not have to travel so far. 
So those doctors at that postacute-care clinic, we are talking 
together to find a safe, equitable way for us to educate the 
people of Baltimore.
    Mrs. Rodgers. Thank you for sharing.
    Dr. Deeks, I heard about a recent study of patients 
diagnosed with COVID-19 that found, 6 months after their 
diagnosis, a third of them were experiencing psychiatric or 
neurological illness. Would you speak to what we know about the 
impacts of COVID-19 on mental illness?
    I think you are muted. Sorry.
    Dr. Deeks. I have been doing this for a while. I should 
figure this out.
    So you can't untangle these things, right? The mental 
health issues, anxiety, depression, they contribute to physical 
symptoms, and physical symptoms contribute to them. And this is 
particularly true of people who have the neuropsychiatric 
flavor of the symptom, but it applies to everything. So it is 
an absolutely critical part of what people are experiencing 
[inaudible] consequence of what their experience is not known. 
It probably goes a little [inaudible] but it requires access 
that people who have the expertise to treat it. It is a big 
part of people's--what they are experiencing.
    Mrs. Rodgers. Thank you.
    Dr. Possick, I just wanted to ask you very quickly about 
young people in particular who are thinking that they are 
invincible to COVID. Would you tell us about the importance of 
increasing public awareness about the post-COVID-19 disease and 
especially highlighting the mild acute illness and what young 
people are experiencing?
    Dr. Possick. Certainly. Thank you for the question. Young 
people have been part of our patient cohort from the start, in 
part because of the healthcare workers that we were treating 
early on, a lot of them were young Black women. But as time has 
gone on and vaccines have been rolled out to older and at-risk 
individuals first, our clinic population has shifted younger 
and younger.
    These patients often report that they were minimally sick 
at the onset and really taken by surprise with how much they 
are struggling now. I think it is difficult to message, but an 
important part of the message that I think, as Lisa said, you 
know, it is not a binary outcome, survival or not. There are 
many possible downstream effects of getting ill with COVID-19, 
and this is an important one for people who view themselves as 
low risk or no risk need to hear about.
    And we need to also work to understand and address what 
motivates vaccine reluctance so that we aren't simply finger 
wagging, that we are engaging in that dialogue and 
understanding what that is about.
    Mrs. Rodgers. Thank you so much. Thank you, everyone.
    I yield back, Madam Chair.
    Ms. Eshoo. I thank the ranking member. Yields back.
    There are many Members that rank on the list here in terms 
of themselves presenting themselves this morning, but there are 
at least maybe 10 that are not available. So I am going to go 
to and recognize Congresswoman Dingell from Michigan for her 5 
minutes of questions.
    Mrs. Dingell. Thank you, Madam Chair. And I want to thank 
all of the witnesses for your patience today but also your 
testimony.
    I have to tell you that--and you can tell as Members have 
been talking to you that there have been patients that have 
reached out to us, told us their stories. And we know the 
trauma many of you are suffering from, of people even taking 
you seriously, where do you go, how do you get support, et 
cetera. So what I have found very impressive in the testimony 
today and in discussions with other people is the Patient-Led 
Research Collaborative. The U.S. has unmatched research 
infrastructure, and we have started to advance patient-centered 
research through organizations like PCORI.
    But I am really impressed with the ability of patients to 
self-organize around a new condition like long-haul COVID and 
get your voices together and to be effective quickly. And I 
think that is really important and to get your results quickly 
into the medical literature.
    So I would like to ask Ms. McCorkell some questions. Thank 
you for being here, first of all. Can you share more about the 
patient-led research group and how your team formed?
    Ms. McCorkell. Yes. And thank you so much for those really 
kind words. I completely agree with you that patient-led 
research is filling a gap right now.
    So Patient-Led Research Collaborative formed back in April 
of last year. We just celebrated our 1-year anniversary. And it 
was after all five of the team leads, we all got sick in March 
and realized after a month that we were still. We joined the 
Body Politic support group, which has helped so many people 
just find a community of other folks who are going through the 
same thing. And we all have research backgrounds. Mine is in 
policy. And we realized that there was just so much information 
being shared and someone needs to document it, because it was 
clear at that point, which was April of last year, no one was 
really paying attention to us. Doctors were gaslighting us. We 
weren't able to get tested. And the media at that point wasn't 
covering us either.
    So we put out a survey, we got 640 respondents, and that 
was the first research on long COVID. And I think that really 
helped to bring to the forefront of the conversation this issue 
and this illness. So that is a little bit about how we formed.
    Mrs. Dingell. And I hope that you all at our hearing today 
and are going to take back to your coalitions that we are 
hearing you. And that is why Chairman Eshoo doing this hearing 
is so important, because you are helping spread the word via 
this, and we want to support you. But my next question is, how 
is your organization engaging with researchers at the NIH or 
with PCORI? How are we making sure it is coming together the 
way it needs?
    Ms. McCorkell. Yes. So thankfully we have had a lot of 
outreach with different researchers, and there are definitely 
researchers out there that we have been in conversations with. 
We actually have applied for part of the funding that NIH is 
providing. So I guess we will hear back from Dr. Collins in the 
next few weeks. So we have applied in partnership with other 
researchers on that funding.
    So with PCORI as well we are hoping to do a project with 
them. So we are in communication with a lot of folks.
    I think our biggest hope, though, is that, you know, there 
were over 200 applications for this NIH funding, which is 
awesome. But our worry is that not all of them are going to 
incorporate the patient voice. Not all of them are going to 
incorporate the patient voice, not all of them are going to 
incorporate past research into post-viral illness, like ME/CFS, 
not all of them are going to incorporate ME/CFS patients. And 
these are very critical in order to actually create findings 
that are going to be useful for long-COVID patients.
    Mrs. Dingell. Well, I am running out of time. So I think if 
we could maybe get your input for the record on some issues, 
like how do we advance patient engagement in our country's 
research efforts, and how do we build--would it help us build 
trust in research and diversity efforts?
    But I really hope you are hearing from Republicans and 
Democrats alike. There is no--we are hearing you, and we want 
to help you all. And I have heard from people in my district, 
as you all are saying, ``People don't believe us, they don't 
know it.'' We believe you, and we are here. We are going to 
help you.
    So, thank you, Madam Chair.
    Ms. Eshoo. The gentlewoman yields back, and thank her.
    A pleasure to recognizes Dr. Burgess for your 5 minutes of 
questions.
    Mr. Burgess. Thank you.
    Appreciate everyone being on this hearing and staying 
around for this part of it. It is so terribly important. And 
just like every other Member, I have heard from a number of 
people [inaudible] different time there was something called 
Gulf War Syndrome. And while my clinical practice was not 
taking care of people who had Gulf War Syndrome, my clinical 
practice was taking care of a number of spouses of people with 
Gulf War Syndrome and the original assignments that this is 
malingering, imagined, it is not real.
    It was actually the actions of Ross Perot, Sr. who got some 
epidemiologists at Southwestern Medical School involved and 
discovered an actual pathologic pathway where there was an 
inactivity of one of the pseudo phosphodiesterases enzymes, and 
these people could not metabolize even small amounts of nerve 
gas that they might have encountered in the first Gulf War. And 
as a consequence, they ended up to go on first with a set of 
nonspecific symptoms but then did progress to something that 
very much resembled ALS. But by the time that was in evidence, 
it was probably past the point of being able to do much besides 
just make someone comfortable.
    So this work that is going on is so incredibly important. 
And I appreciate so much patients, I appreciate the clinicians 
who are working on this, and I know it is not easy, and I 
appreciate the perspective the patients are bringing to us. It 
is hard to not be listened to. And let me just tell you, from 
the standpoint of someone who at one time ran a very, very busy 
medical practice, you get behind and you are able to devote 6.2 
minutes to every patient, and it can be hard to give the proper 
amount of attention.
    And I guess what I would ask Dr. Deeks and Dr. Possick on 
the call, is it possible with what we know now with 
telemedicine with the way that has come into its own, is it 
possible to provide some additional help to the people on the 
front lines, both diagnostic and/or some of the therapeutic 
interventions that might be entertained?
    Dr. Possick. I can tackle that first. I think I would say 
that we found telemedicine to be indispensable. We probably 
were late to adopting it the way we should have, and COVID-19 
forced our hand in a good way. It has been helpful. We need 
better support and infrastructure for it, because telehealth is 
not an equitable access resource for all patients. And there 
are barriers to reaching people who have technology barriers or 
health literacy barriers in other ways. But I do think that it 
will play an important role.
    We use it interchangeably with our face-to-face visits now, 
depending on where our patient is and what they can manage, 
because navigating all this multidisciplinary care is 
exhausting for people. And sometimes it is easier for them to 
engage with a visit from their home than to come into the 
clinic.
    Mr. Burgess. Sure.
    And, Dr. Deeks, do you have anything you would want to add 
to that?
    Dr. Deeks. Well, if you had a lot of money, you would do it 
right. If you would do what you did with the Ryan White 
programs, right, which was money was basically put aside in 
urban centers to provide disenfranchised, uninsured people who 
had HIV with access to these integrated-type clinics in which 
they didn't have to worry about paying for anything. They just 
showed up and they got everything they needed. And it was 
incredibly therapeutic and effective. And, you know, 
ultimately, I----
    Mr. Burgess. Let me just ask you----
    Dr. Deeks. Initially----
    Mr. Burgess. We had some experience with Project ECHO in 
more rural parts of my State where the access to specialists 
can be a force multiplier for patients who wouldn't have the 
availability of sophisticated specialists. Is that something we 
can incorporate into the care of a long-COVID patient?
    Dr. Deeks. Since there's so many specialists involved and 
there is a need to bring them to the same place so people can 
navigate it, yes. How they go about doing that is going to 
require resources and some original thinking.
    Mr. Burgess. Yes. You know, I was thinking when Dr. Collins 
was talking about, you know, some of the things that we don't 
know, is this a lingering effect of the virus in someone's 
system? Is this an effect of a vasculitis? And then he 
mentioned a third thing that now I don't recall off the top of 
my head. But there is a possibility it is also in the 
individual, it may be any one of those things. In some there 
may even be a combination or a spectrum. It just strikes me 
there is a lot we have to learn about this. But anything we can 
do as a force multiplier on the provider side is ultimately 
going to benefit our patients. And, clearly, with the stories 
we have heard today, we are not doing necessarily the best job 
in hearing and listening to the patients who have presented to 
us today.
    I thank you all for your input on this committee. It has 
been very valuable. I will probably have some questions to 
follow up on the questions for the record in a written 
response. So thank you all for being here today.
    Ms. Eshoo. The gentleman yields back.
    And it is a pleasure for me to recognize the gentleman from 
California, Mr. Cardenas, for your 5 minutes of questions.
    Mr. Cardenas. Thank you very much, Madam Chairwoman. And 
once again, thank you and to the ranking member for having this 
important, important hearing and certainly bringing on this 
second panel to enlighten us some more so that we can make 
better decisions with the taxpayer dollars and also with the 
policies that we advance across the country. So thank you all 
very, very much for being here to help enlighten us.
    I also want to especially thank all of the witnesses and 
those of you who have given us your heartfelt experiences. And 
you have been willing to share with us in view of every person 
who chooses to tune in across this country. And these are 
important stories because they are real stories. And we have to 
do things to make sure that they do not repeat themselves. This 
is literally life and death that we are talking about.
    My first question is to you, Ms. Smith. In your testimony, 
you express that you carry the weight of other Black women who, 
like you, have been misdiagnosed and frightened. But also I am 
going to put upon your shoulders, you have expressed what I 
heard personally from Hispanics, from Native Americans, and a 
lot of people who have, unfortunately, received less than the 
care that should be available to them when somebody else is, 
rightfully so, getting that care. So thank you for being here 
and representing yourself----
    Ms. Smith. Thank you.
    Mr. Cardenas [continuing]. And especially those people and 
every person--man, woman, and child--who has received less than 
what merits them in our amazing system when it works well.
    My first question to you is, do you think racism exists in 
America? And is it limited or does it stop at the door of 
healthcare?
    Ms. Smith. It absolutely exists in America. I have 
experienced it. I am a middle school teacher in Baltimore, 
Maryland, and I have experienced it even in some of these--on 
some of these, you know, meetings and organizations and 
corporations and these talks. While I am excited and thankful 
for the opportunity, I still see that we are doing a--we are at 
a deficit with how we include Black stakeholders and 
researchers and scientists and doctors into this conversation. 
It is what--before I became ill last March, it is what I tried 
and strived so hard to teach my students about. We were in--you 
know, I teach low-income students and families but in an 
affluent neighborhood. I wanted them to be aware that just 
because they were Black and sometimes underrepresented, that 
they still had a place in the educational system.
    As I mentioned in my testimony, I had been repeatedly, 
repeatedly racially profiled over the course of the last year. 
I think the assumption for me is that because I am Black and a 
woman in a low-income neighborhood, that I am not aware of my 
body, that I can't research what is happening to me, and that I 
am not articulate enough to share those experiences. But what I 
think I have been able to do is to challenge that perspective. 
And so I also have talked to other women--I talk to them every 
day--and our fear is that we will be left behind because we may 
be too afraid to speak out.
    So it is my hope to challenge doctors who racially profiled 
me, who called me too aggressive, who used microaggressive 
language with me to change the dynamic and change the narrative 
of what long COVID looks like. It is not just a White woman's 
disease, and, sadly, that is the way it has been painted.
    Mr. Cardenas. Well, thank you for expressing those truths.
    And one of the things that I would like to point out, I 
know the word ``racism'' hits people like a dagger.
    Ms. Smith. Yes.
    Mr. Cardenas. And I think some people think that somebody 
who is expressing or treating somebody in a racist way has got 
a bad heart. Unfortunately, I think many times it is just 
ignorance. It is just the person doesn't recognize that we all 
have biases, doesn't recognize that this person whose voice 
might be a little different than mine, whose mannerisms might 
be a little different than mine or what have you, it is not a 
negative thing, it is just different. It is just different. 
But, unfortunately, the weight of those actions day after day, 
especially when your life depends on this person giving you the 
respect and the attention that they are actually paid to give 
you, the respect and the attention you have actually paid for, 
it is kind of like, if I were to put a little pebble in my 
hand, I could hold it, but add one pebble and 1,000 pebbles and 
2,000 pebbles and somewhere along the way, my arm is going to 
go down because the weight is too heavy.
    So I just want to say how much I appreciate you coming 
forward and expressing yourself and enlightening us to the fact 
that racism isn't something that starts from ugliness, but the 
results of racism far too often are ugly, they are damaging, 
and in some cases could lead to ending someone's life. And 
entire communities are receiving that. And it is important that 
we recognize that we are not calling people bad people who 
participate in contributing to that. We are just saying please 
look in the mirror and recognize it, check yourself. And if 
somebody checks you, please understand, be open, be open to 
being checked, and then be willing to apologize if you 
recognize that you have acted in ignorance.
    So, anyway, I apologize for going over my time, Madam 
Chair. Thank you all so much for coming today.
    Ms. Eshoo. Wonderful. The gentleman yields back.
    A pleasure to once again recognize the gentleman from 
Virginia, Mr. Griffith, for your 5 minutes of questions.
    Mr. Griffith. Thank you very much, Madam----
    Ms. Eshoo. There you are.
    Mr. Griffith. I am here. Thank you very much, Madam Chair.
    Ms. Eshoo. Sure.
    Mr. Griffith. I do appreciate it.
    Dr. Deeks and Dr. Possick both, as you may have heard in 
the prior--and I understand it has been a long day--but in the 
prior testimony, I talked about a friend of mine who has long 
COVID. He has been in and out of the hospital four times, 
mostly with breathing issues and, of course, just generally 
being weak. His doctors are telling him that, you know, as he 
moves along, that he should be doing, you know, more exercise 
and that that will take care of the problem.
    Do you think that makes sense, or is it just that every 
case is so different that it is just very hard to say what 
makes sense across the board? Go ahead and start, Dr. Deeks, 
and then, Dr. Possick, if you want to.
    Dr. Deeks. Well, Dr. Possick is an expert on this very 
specific issue, so I will defer to her.
    Mr. Griffith. All right. That would be fine.
    Dr. Possick. I think we have seen great value in many 
different kinds of rehabilitation therapy for our patients, 
which may not be true for all patients. But I also think that 
we have to approach statements about rehabilitation carefully, 
because it is not a one-size-fits-all solution and has to be 
adapted to the patient in front of us: their particular 
condition, their particular symptoms, our hypothesis about why 
they feel the way they do, and how they respond to initiation 
of rehabilitation.
    And it is not merely physical rehabilitation. It can 
involve speech therapy, cognitive therapy, occupational 
therapy, and specialized programs like pulmonary rehab and 
cardiac rehab. And the appropriate solution for any given 
patient requires assessment by a professional in physiatry or 
physical therapy.
    Mr. Griffith. And I think what makes it so difficult, from 
listening to the testimony of you all today and our prior 
panel, because, originally, my questions were what is the 
answer and what should the fix be, what should the treatment 
be. And it sounds like it is different for every person. And 
doesn't that make it difficult for the frontline physician or 
medical care professionals? Because somebody comes in 
presenting, it may not be the same way that somebody else with 
long COVID presented just last week. And doesn't that make it 
hard on the primary care doctors to be able to figure out that 
they are dealing with long-term COVID issues?
    Dr. Possick. That is true, but it is not true of only this 
circumstance. We face that with a lot of different medical 
conditions. And there is a high degree of heterogeneity in 
nearly every disease that we treat.
    I think that a starting place is dialogue like this, and 
also definitions and best practice guidelines from CDC and from 
professional organizations that then give frontline primary 
care providers a tool to tease out what they think is going on 
with any particular patient in front of them.
    But, you know, heterogeneity is not novel to this one 
circumstance. It is something that we face in a lot of cases. 
But we need to just start by acknowledging that that is also 
the case here.
    Mr. Griffith. Yes. And I think this hearing is good, and so 
I appreciate your time in this long day, and everybody's time 
on the panel this long day, because I think there is a public 
misperception on this too. Because I will tell you that I don't 
know exactly why we thought he was getting better and he really 
wanted to get back to work. And at one point, months ago, I had 
lunch with him and then he had a relapse. And I think there is 
this perception that, you know, OK, you had COVID, get over it, 
come back to work or get over it and get back to your regular 
routine. And for so many people, that is just not possible. Is 
that a fair statement?
    Dr. Possick. Yes. I think that, in this condition, like 
many, recovery is not linear.
    Dr. Deeks. So this waxing and waning of symptoms is 
difficult to explain why that would be, but it is very common. 
It is very common. So I don't--we don't have a mechanism for 
it. We don't know why that would be, but it is something, I 
think, certainly in our clinical cohort, we have seen that. 
People have good days, they have bad days. And it is hard to 
explain why.
    Mr. Griffith. Yes. I appreciate that very much.
    And, with that, Madam Chair, I yield back.
    Ms. Eshoo. The gentleman yields back.
    The Chair now recognizes the gentlewoman from Illinois, Ms. 
Kelly, for your 5 minutes of questions.
    Ms. Kelly. Thank you, Madam Chair.
    And thank you to the witnesses and all of your patience.
    Ms. Smith, thank you so much for coming today to share your 
experiences as a Black woman. As a Black woman, I really, 
really appreciate that. You shared some things, but can you 
tell us what areas of opportunity that our healthcare system 
could have supported you more? Like what would you have liked 
to have seen? What do you want to happen? How can you improve 
the system?
    Ms. Smith. Absolutely. Thank you for the question. I would 
have loved from the very beginning to have doctors who 
documented my experience and the narrative that I shared with 
them about my experiences. What I find now is one of my biggest 
problems, and I know it is the problems of many long-COVID and 
ME and CSF patients, is that the notes that are being written 
about us do not depict an accurate picture of our experiences.
    I have had to go through pages and pages and pages of 
medical records that don't even indicate that I said as the 
patient that, even though I tested negative for COVID, that I 
believed--even though I tested negative, that I believed that I 
have it. And so--there has also been so much inaccuracy in what 
has been reported about me.
    I have been recently reading a doctor who says that he 
doesn't know whether I worked over the last year. I can tell 
anybody that I have not worked a single day since March 23, 
2020. And so it is my hope that, especially in the Black 
community and other urban areas and even rural communities, 
that our narratives, our experiences are documented into those 
notes.
    It makes our lives a little bit easier when that happens, 
because now I am facing challenges with my employer because of 
the notes. I was dismissed from the NIH studies because they 
claimed that I didn't have medical notes that represented my 
condition.
    And so copious notes from doctors are so important, and 
ironically I just got an email from a doctor recently as a 
couple minutes ago who said that he has added my experience to 
documentation.
    So that is going to help me when I apply for disability 
benefits, which I know I will need in the next couple of 
months. So that is the most important step that we can make to 
helping long-COVID patients.
    Ms. Kelly. Thank you so much for sharing. I am the chair of 
the Congressional Black Caucus Health Braintrust, and I do a 
lot of work around maternal mortality and what has happened to 
Black women. So I appreciate you sharing. We need more people 
to do that.
    Dr. Possick, as we know, COVID-19 disproportionately 
impacted Black and Brown communities, which is evident in that 
data of infection rates and mortality rates. And it seems like 
we are seeing this trend in long COVID disease. What barriers 
are keeping people from receiving the equitable post-acute care 
that you state is necessary for all to receive?
    Dr. Possick. There are many. I think trust of the medical 
system is one. They can be more prone to be reluctant 
reporters, particularly if they are trying to return to work, 
return to their lives. There is a stigma associated with 
reporting these symptoms at all, and if they have encountered 
discouraging interactions early on, then they stop offering up 
the symptoms.
    I think that, for working people, it is difficult to access 
medical appointments, period. Even if you can get an 
appointment, getting time off of work to go and do that, engage 
in the testing, engage in therapy can be really prohibitive. If 
I tell a patient of mine I think they need to go to see three 
other people, how can they possibly do that if they are also 
trying to earn a wage?
    So I think that those are among the issues, you know, 
particularly with respect to underserved populations and people 
who don't have access to transportation, to telehealth-ready 
devices, that it can be very difficult to access care from afar 
that other people of means can. And also just generally 
navigating the system, trying to work through how to apply for 
workman's comp for disability is incredibly complex. And so, 
without empowering people and helping them to access those 
services, they just face insurmountable challenges.
    Ms. Kelly. Thank you so very, very much and thank all of 
you for being here today.
    I yield back, Madam Chair.
    Ms. Eshoo. The gentlewoman yields back. Pleasure to 
recognize the gentleman from Florida, Mr. Bilirakis, for your 5 
minutes of questions.
    Mr. Bilirakis. Thank you so much, Ms. Chair. Thank you very 
much. This has been a great hearing, a bipartisan hearing, and 
I appreciate that so very much.
    Ms. Kelly. What you need real quick what I am setting up 
for them?
    Mr. Bilirakis. Can you hear me? OK.
    Ms. Eshoo. If Robin Kelly would mute. OK?
    Mr. Bilirakis. OK. All right. We are good. We are good.
    Dr. Deeks, is there a universal definition for long-term 
COVID, or is it a catch-all term?
    Dr. Deeks. There is not even an accepted name, let alone a 
definition.
    Mr. Bilirakis. Yes, yes. So the lack of standardization, 
does it impact research? And if so, how, and how can we 
standardized--how can it be addressed? I know it is tough, like 
you said. It is a very difficult to get your arms around it, 
but please if you could respond.
    Dr. Deeks. Yes. So I think Dr. Possick is maybe involved in 
some of these discussions more than me, but there is--there is 
an effort underway by various people around--various groups 
around the world to come up with case definitions. And my 
concern is that we may end up with several, and everyoneis 
going to use things that are different, but it is an absolutely 
essential thing--do you have any comments on this, Dr. Possick?
    Mr. Bilirakis. Yes, Doctor, please.
    Dr. Possick. Yes. I think that when I read these very 
important and enlightening studies that are based on EMR 
culling of data, I wonder about who we are missing. Because 
when I see a patient in a visit and I enter a diagnostic code, 
I have to use what I think best aligns with the patient I am 
seeing. So, even if I use a code that includes a personal 
history of COVID-19 or suspected COVID-19, the primary 
diagnosis may still be the thing that I am seeing them for.
    So pulmonary infiltrates or interstitial lung disease or 
shortness of breath, and because we all approach this and code 
in different ways, because we are just trying to do our best, I 
don't know that studies that rely on EMR data are capturing 
everyone whereas, if there was adoption of uniform ICD-10 code 
for post-COVID conditions, yes, it might be a relatively blunt 
instrument that doesn't capture the phenotypic diversity, but 
it would at least identify people more readily. And I think 
that is really important.
    Mr. Bilirakis. OK. Thank you.
    Dr. Deeks, why do COVID long-haulers initially seem to be 
asymptomatic only then to suffer these devastating symptoms 
like, again, we had with one of the presenters today? Can COVID 
hide in our system? If so, what does that mean for diagnostics 
and targeted therapies? And what are the most common long-term 
symptoms of COVID-19?
    Dr. Deeks. Let me deal with the first one, which is the----
    Mr. Bilirakis. Sure. Absolutely. Please.
    Dr. Deeks. That is my area of expertise. Why would 
someone--so people who have very little symptoms begin with----
    Mr. Bilirakis. Yes.
    Dr. Deeks [continuing]. Probably don't have much virus to 
begin with.
    Mr. Bilirakis. OK.
    Dr. Deeks. So why would those people be sick months later? 
It is the way--these people when they are exposed to anything, 
just a little bit, it sets off an inflammatory response, an 
autoimmunity. So people develop antibodies to their own body, 
and that makes them sick. That is a leading theory for why 
someone who--it doesn't take a lot of virus in the right person 
to stimulate these autoimmune disorders. So that is--as to what 
the most common symptoms are, I don't know.
    Dr. Possick sees these patients more than me. What do you 
think?
    Dr. Possick. So, depending on the study you look at, you 
get different statistics and ranking for that. I am a 
pulmonologist in a lung clinic. So the most common symptom I 
see is shortness of breath, probably followed by tachycardia, 
fatigue, and what I would broadly term exertional intolerance. 
And sometimes orthostatic intolerance like difficulty sitting 
or standing for a long period of time, much less exerting one's 
self, but really we have seen symptoms that span every single 
organ system, depending on the patient.
    Mental health symptoms are very prevalent, both in the 
population that was hospitalized and those that were not. And 
this includes new mental health symptoms, not just exacerbation 
of preexisting conditions.
    Mr. Bilirakis. OK. Well, thank you very much. I know my 
time has expired, but I appreciate it very much. Thanks for the 
testimony. We learned a lot today. I know there is more to 
come. So thank you, Madam Chair.
    I yield back.
    Ms. Eshoo. The gentleman yields back. And I appreciate his 
questions and comments.
    I now would like to recognize the gentlewoman from 
Washington State, one of our great doctors, Dr. Schrier. 5 
minutes.
    Ms. Schrier. Thank you, Madam Chair.
    First, let me just say to our three patients--Ms. Smith, 
Ms. McCorkell, and Ms. Hakala--I just have profound sympathy 
and empathy for you, and I am so sorry for what you are going 
through and the way that you have been treated. And I do 
understand that--you know, that struggle that doctors go 
through when it is so frustrating to not be able to put your 
finger on it and do something, but I just want to express that 
sympathy.
    To Dr. Possick and Dr. Deeks, thank you for diving in and 
embracing this uncertainty and the patients who are in distress 
where you don't necessarily have a way of fixing. And I am 
listening to all of these comments and thinking that, of 
course, we need research at the NIH and CDC, but I am thinking 
about the things that Congress can do, like how can--this is 
the doctor thinking--like what can we do?
    And one it sounds like we need to work with CMS to get an 
ICD-10 code, even if it is sort of like possibly in post-COVID 
symptoms not otherwise specified, something along those lines. 
It sounds like we really need to continue to work on our social 
safety net and healthcare coverage and FMLA to just keep people 
afloat. And it also sounds like we kind of need like a new RADx 
or a new warp speed to try to just take a stab at possible 
therapies. And so I guess my first question--I have a couple 
questions about this. One is we heard from Ms. Smith and Ms. 
McCorkell about negative antibody tests leading to this 
reluctance to diagnose, and I was just wondering, Dr. Deeks, 
could you talk about how common this lack of an antibody 
response is, and maybe does that then suggest a pathway to this 
maybe being like a chronic viral infection that never really 
stokes the immune system?
    Dr. Deeks. So great question. Depending on how you define 
it, maybe about 10 percent of people who develop COVID end up 
being--either have low antibodies or they are sero negative. 
They don't actually sero comport. Their antibodies remain 
negative. And, interestingly, those are the people you would 
think would have a lot of virus that would persist particularly 
in tissues. And, interestingly, those are the people that you 
would think would benefit from a therapeutic vaccine. They 
didn't generate an immune response. They have no antibodies. 
The virus is around causing disease. You get a vaccine. Now, 
they have antibodies. The virus goes away. And I have heard 
many anecdotes of people who have done that.
    So it is one of those testable hypotheses. So we need to go 
out and find people who are antibody-negative who have these 
symptoms and do special tests to see if they are truly 
infected. And they are easy to do, but only in research 
centers. And to be honest, then you build up the immune system 
to fix it.
    Ms. Schrier. So here is the next question, which is related 
to that, which is kind of like, right now, you have very few 
tools, if no tools in your toolbox. And if there are all these 
different pathways, you know, one is lingering infection, one 
is autoimmune, one is, you know, blood clots. Do you ever 
consider just empirically throwing everybody on aspirin, or it 
is kind of opposite things? Do you just put people on steroids 
for an overresponse or people on some sort of, you know, 
immunomodulator if you think that you are going down an 
autoimmune pathway? I am just wondering if you are already 
thinking through those possible treatments.
    Dr. Deeks. Yes. So that is happening, right. So you go to 
clinics right now, and people will be doing that. They will be 
giving statins because they are antiinflammatories. They will 
be given hydroxychloroquine because it blocks certain 
inflammatory pathways, and it is safe, and people give aspirin 
for clotting. And, actually, I think, the various clinics have 
their own sort of brand. And that is what a good clinician 
would do that, right? I mean, you have a person in front of 
you. They are sick. There is no treatment. You do the best that 
you can. There is some rationale.
    And so that is happening. And, from that, people will write 
papers saying, ``Here is my hundred patients. I did this, and 
here is what happened.''
    And that will lead to clinical trials. So we are in that 
process right now where I think clinicians are making it up as 
they go along, as they should, doing the best that they can and 
teaching each other what is happening.
    But it is going to be years before we have targeted drugs 
and randomized clinical trial data. In the meantime, I think, 
not everyone would agree, you are somewhat obligated to try 
your best.
    Ms. Schrier. I hope it is not years. Thank you very much.
    I yield back.
    Ms. Eshoo. The gentlewoman yields back.
    Pleasure to recognize the gentleman from Georgia, Mr. 
Carter, for your 5 minutes, followed by Mr. Doyle of 
Pennsylvania. And I don't have any other Members on tap. So 
take it away, Mr. Carter.
    Mr. Carter. Thank you, Madam Chair.
    And thank you, Dr. Possick, Dr. Deeks for being here. We 
appreciate this.
    Dr. Possick, I wanted to ask you, in your written testimony 
you mentioned that many of your patients are young adults and 
adolescents. Why do you think that is?
    Dr. Possick. Well, young adults certainly. We are not a 
pediatric clinic, so haven't been seeing adolescents, but, you 
know, I think it reflects potentially many things. We don't 
know if perhaps younger people are more susceptible. There are, 
as was referenced before, a large number of people in the 18-
to-39 age group who have been infected with COVID. As time has 
gone on in older individuals and at-risk individuals have been 
vaccinated first, we have seen the age profile of our clinic 
population shift down. It is also possible that sicker people 
with more comorbidities at baseline and a higher level of 
disability at baseline don't register the changes to their 
health in the same way that a healthy long-distance runner who 
was working for a time would, right?
    So some of it is where you started compared to where you 
are, but I do think that there are--especially now a lot of 
young people who are getting newly infected, unfortunately. And 
that is reflected by the patient profile that we are seeing in 
our ICUs as well, to some extent.
    Mr. Carter. What are the treatments that are working?
    Dr. Possick. I don't think that we can broadly say that 
there is any treatment that is working for all patients. We 
don't have that answer yet. As Dr. Deeks had suggested there 
are things we try empirically. Sometimes they work for some 
patients, other times not, but we are not in a position yet to 
say that this is the regiment, this is the treatment that 
works.
    Mr. Carter. You mentioned something a little while ago that 
concerns me, and that has to do with about how can we ensure 
that we don't have a stigma that develops along with those who 
have long COVID? I am very concerned about that, and obviously 
you are too.
    Dr. Possick. This hearing is an important place to start. 
The fact that you have invited patient panelists is incredibly 
important and sends an incredibly important message to the 
establishment and to our whole community, but I think that, 
again, naming has a powerful message. So arriving on agreed-
upon terminology for what patients are experiencing, then going 
on to create our best guess at clinical criteria for what that 
is, is important so that we can acknowledge and validate what 
people are experiencing.
    Mr. Carter. Dr. Deeks, any comments from you on that?
    Dr. Deeks. I am passionate about that last question. You 
know, HIV--we treat HIV, but people with HIV have stigma. It 
never goes away, and maybe a couple days of living in that kind 
of environment, but years of feeling--it wears you out. It is a 
huge impact.
    So we have got to destigmatize this syndrome--give it a 
name, find a mechanism, have congressional hearings, have the 
NIH devote a billion dollars to it. This is all good, and all 
the media that is happening because these very powerful patient 
groups, their impact is through the media, right? The New York 
Times, Washington Post have been covering this extensively, and 
that is partly why we are here today.
    So the stigma is something we are fixing, and I cannot 
overemphasize how much respect I have for this group spending 
an entire day talking about this. I can't get doctors to spend 
a whole day talking about this. So what you are doing today is 
very therapeutic.
    Mr. Carter. Well, thank you both for mentioning that about 
the stigma part of it. I mentioned in the first panel that I 
have got a dear friend who is, unfortunately, suffering through 
some psychotic episodes and mental health issues as a result of 
this, and that concerns me because I am very concerned about 
his health, but this is real.
    I think a lot of people said, ``Oh, I had COVID, and I 
didn't even know it.'' And they just kind of passed it along as 
being something that is not serious, but it is serious. And it 
is something that we have to take seriously.
    So thank both of you for being here today. And thank you, 
Madam Chair. This has been a truly bipartisan hearing and a 
good hearing today, so thank you for this.
    And I yield back.
    Ms. Eshoo. The gentleman yields back.
    Now I believe, last but not least, my pal, Mr. Doyle. You 
can wrap it up for us today. Five minutes.
    Mr. Doyle. Thank you, Anna. And thanks for holding this 
hearing. It is. It is very important. Thanks to both panels, 
especially the second panel because you guys had to sit here as 
long as we do. It is our job to sit here through the hearing, 
but boy, sometimes when you are on that second panel, this can 
be difficult. I really--I just want to thank Dr. Deeks and 
Possick for being here. The questions I had were the ones I 
wanted to talk to the NIH about, but I just stayed on, Anna, 
because I wanted Chimere and Lisa and Natalie to know that, to 
hang in there.
    My son Kevin is a COVID long-hauler. I have been watching 
this up close and personal every day how this young, healthy 
athletic person, who was the most physically fit guy in our 
family and had COVID and had no--wasn't hospitalized. You know, 
couple days he didn't feel good and remember him calling me on 
the phone and said that was nothing. And here we are going on 4 
months later with the, you know, sleep disorders and the 
trouble breathing and pain in his chest and just this fatigue.
    This is a guy who couldn't sit at a house. I mean, he was 
just out exercising. He has a gym in his basement that he works 
out in every day, and now he can't get out of bed sometimes and 
had to start going on disability at his job. So, you know, 
there is a lot we don't know about this yet, but there is a lot 
we do know. And there's doctors out there, by the way, that are 
treating. You are not going to get treatment in the 
establishment hospital. I live in Pittsburgh. We have one of 
the largest academic medical centers in the country, UPMC, and 
we have Allegheny General. And they have COVID long-hauler 
clinics.
    But right now there is really no treatments there. You go 
there--because my son has been to both of them, and they ask 
you a bunch of questions, and, you know, and they treat 
symptoms. If you say you are having trouble breathing, they 
will let you see the pulmonologist. If you have neurological 
problems, they will send you to the neurologist. But they are 
not treating--there is not a prescribed approved cure or 
treatment, I should say, for COVID long hauler right now that 
NIH or FDA or CDC--but there are doctors out there, as Dr. 
Deeks said, trying to do their best with what they can. There's 
antiviral medicines out there. There's other medicines that 
have been used to treat HIV/AIDS.
    I know the regimen my son is on, and it is starting to help 
him. But know this: We are going to continue to push the people 
here at NIH and CDC to make sure that we are not leaving any 
stone unturned. We may not need to reinvent the wheel. That is 
why I pressed the NIH to also test some of these drugs that are 
available that are off-label right now being used to see if 
they are effective or not. And, you know, we have really got to 
press--we have got to do research. There is no question about 
that.
    NIH does a great job. We have given them the funding they 
need, but they need to also step up their foot on the gas on 
treatment because there is a lot of you out there suffering 
every day, and I know you can't wait a year or two for some 
study to come back saying we think we have got this figured out 
now.
    So I just want to thank the three of you for coming and 
telling your stories, and that is the only reason I stayed on 
for this second panel to make sure that I expressed to the 
three of you that we all have a lot of empathy for what you are 
going through.
    And Anna, thank you. This is an important hearing that we 
needed to have, and we need to like--we need to not forget 
about it after this hearing. We need to keep pressing ahead, 
and I know you will. So thank you for that. And that is all.
    I will yield back my time.
    Ms. Eshoo. Well, thank you, Mike. And I think that, too, 
our patient witnesses that you wouldn't have thought that you 
would hear a Member who is a dad and described his son and what 
his son is going through. But this virus is not discriminatory. 
It doesn't care--it doesn't regard ZIP Codes, job titles, and 
all of that.
    All of my thanks on behalf of all of the Members, and many 
of them have signed off because they already got to ask their 
questions and we have been together for a long time today. I 
also thank you for listening in--not necessarily being part of, 
but you were there for the first panel, and I can't help but 
think that what they shared with us is important information to 
you because it is a piece of it. It is not all of it, but it is 
a very important piece of it. And that very important piece, 
the Congress has already put in place significant dollars for 
the research.
    To each one of you, we really are very, very grateful to 
you. There is nothing like the voices of those that are the 
ones that are affected, but then also those that are the 
professionals that are one-on-one with the patients, know the 
setting, know where the shortfalls are.
    To Dr. Deeks, you are looking way into the future using the 
experience of your work of the past with HIV/AIDS patients, and 
I think that that is highly instructive as well. So, you know 
what? We have been the students, and you have been the 
teachers, and for that, we are all very grateful. And we are 
not going to let go of this. Seems to me that we need to come 
up with a designation and go from there, but in between the 
responses from the researchers and others, we need to have 
wraparound services for people because they can't function.
    I mean, you know, you have said over and over again, you 
have told your stories and left an imprint on us of how 
debilitating this is and that, you know, with that 
debilitation, what do you do? You can't--you simply can't 
function. So we need wraparound services that are designated 
for those that have this.
    So bravo to all of you and our thanks. Many Members will be 
submitting written questions to you, and we ask you to respond 
in a very timely way, and we thank you in advance for that.
    So now we have just a little housekeeping, and that is that 
I want to ask my colleague, we do have 12 documents to submit 
to the record, Mr. Guthrie. I don't think you want me to read 
through all of them. I am sure they are all important and 
wonderful documents for the record.
    So I would ask for unanimous consent, to put in a unanimous 
consent request that the statements be placed in the record.
    Mr. Guthrie. OK. Before I say I don't have any objection, I 
just want to say thanks to all the witnesses too. Your 
testimony is compelling. The physicians that have been on, the 
healthcare providers that have been on this, and we are dealing 
with this in real time, and we are learning as we go and we are 
making a big effort to really understand this on both sides of 
the aisle, and your testimony today was very helpful. Very 
helpful in that. And so we thank you so much.
    And I don't have any objections. I assume everything we 
submitted is on the list there. I think our staff has looked at 
that, so I don't have any objection.
    [The information appears at the conclusion of the hearing.]
    Ms. Eshoo. OK. Thank you, Mr. Guthrie.
    And pursuant to committee rules, Members do have 10 days to 
submit your additional questions for the record. And I have 
already asked that the witnesses respond promptly to any 
questions that you have received.
    And with that and our collective thanks, the subcommittee 
is now adjourned.
    Thank you, everyone.
    [Whereupon, at 4:56 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]
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