Veterans Health Administration takes on one of the pandemic’s most vexing challenges

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For many people who contract the COVID virus, the illness comes and goes. Others develop what’s known as long COVID. Symptoms last weeks or months. The Veterans Affairs Department has developed what it calls a whole health approach to long COVID. With how VA practitioners are dealing with long COVID, the Federal Drive with Tom Temin spoke with Dr. Elizabeth Brill, the deputy assistant undersecretary for health.

Tom Temin: Dr. Brill, good to have you on.

Elizabeth Brill: Thank you very much, good to be here today.

Tom Temin: And let’s just set the scene here. What exactly is long COVID? I guess it’s kind of self explanatory. There’s a lot to it, isn’t there?

Elizabeth Brill: Yes, there is. So there are some varying definitions by different health organizations. But essentially, long COVID is when symptoms either persist or return long after the initial COVID infection has happened. So four to 12 weeks afterward. And there’s a variety of different symptoms. So not everyone’s going to experience long COVID exactly the same way. Many different body systems are involved.

Tom Temin: And I guess at this point in history, we don’t know how long it can go really?

Elizabeth Brill: That’s correct. We do not know that.

Tom Temin: And how prevalent is this among the veteran population that VA serves? Do we know?

Elizabeth Brill: Well, the studies so far, show long COVID occurs in about 4-7% of patients that have had COVID. However, again, those are early numbers, and we could determine that number to be higher or lower over time.

Tom Temin: And have VA statisticians been able to associate it with any particular demographic? Is it more prevalent in men versus women, age group, or any other pre-conditions that might be extant?

Elizabeth Brill: Yes, it does seem to be more prevalent in women. It is also more prevalent in people that in the early course of their COVID infection, respiratory symptoms was their major complaint, and it also is more likely in people that had a worse initial COVID course, such as folks that ended up in the ICU, rather than someone who was asymptomatic. However, even asymptomatic folks can develop long COVID.

Tom Temin: Wow, so more reasons to be scared, as we think we’re coming out of this. Tell us about the effort in VA to develop the whole health approach that you have.

Elizabeth Brill: So initially, our community of practice, which is essentially a number of clinicians of all different walks, came together organically as they started to see COVID and tried to understand it and share knowledge across the VA system. It became clear as our researchers were observing long COVID — and VA was one of the first to really notice this phenomenon — that we needed to put together a really comprehensive guide that we could share with all clinicians so that they could recognize long COVID and what to do. And so we put together a project team in order to assess, refer and treat long COVID. And that’s the whole health guide that we’re speaking of today.

Tom Temin: And what are the disciplines that came together here?

Elizabeth Brill: Oh, so many, from respiratory to cardiology, to mental health, you name it. There’s about 10 organ systems. So all of these specialists were involved in developing this guide.

Tom Temin: Mental health. That’s an interesting one, too. It sounds like perhaps someone’s mental state condition could have an effect on their ability to fight this?

Elizabeth Brill: So mental health — two components: it is part of long COVID, some anxiety and depression, as well as some brain fog that can occur in long COVID. Furthermore, our approach to treating long COVID is this whole health approach that really involves the veteran in their own care. And so their ability to really connect and focus may be impacted by any underlying mental health conditions that they have.

Tom Temin: And this is just an off the wall question: Are there any service related preconditions such as burn pit exposure, or something like that that is associated with long COVID? Or is that a bit of a stretch?

Elizabeth Brill: Not that we’ve seen thus far.

Tom Temin: We’re speaking with Dr. Elizabeth Brill. She’s the deputy assistant undersecretary for health and clinical services at the Veterans Affairs Department. So what does the whole health treatment consist of? What are some of the elements of it that you’re promulgating?

Elizabeth Brill: Whole health as a concept involves the veteran at the center; they think about what’s important in terms of their goals and what they’re capable of in participating in their own health care. Then there’s a community approach and some alternative medicine approach that goes along with traditional medical approaches such as medications and traditional therapies. And so whole health encompasses all of that together.

Tom Temin: What are some of the non-traditional effects, or things you can take or do?

Elizabeth Brill: Well, we look at biofeedback and acupuncture and breathing techniques, and exercise such as tai chi or yoga. Those are some of the non traditional elements of caring for a veteran with long COVID that, as you can see, they can have a lot of impact on themselves by choosing to elect those therapies.

Tom Temin: I‘m sure that if you looked far enough somewhere someone is prescribing a cannabis or CBD type of approach here. Is that possible within the VA system?

Elizabeth Brill: Not within the VA system per se at this time.

Tom Temin: All right. So does VA itself administer acupuncture and Tai Chi and these kinds of things? Or do you just encourage patients to go seek it on their own, maybe from some of the community care providers?

Elizabeth Brill: Actually, VA offers many, if not all, of these alternative therapies, depending on the location where the veteran is.

Tom Temin: And is one of the theories of this that perhaps it may not do anything, but if you believe it will, kind of a placebo effect, then that’s just as good as if it actually has a physical manifestation?

Elizabeth Brill: So the placebo effect is definitely well described in medicine. And so it is important. And a lot of this therapy has to do with a general sense of well-being. And so if yoga, relaxation, mindfulness increases a sense of well being, then that we would consider success.

Tom Temin: And the guide now that you have published, is that strictly for internal use at VA, or are you promulgating this widely in the medical field?

Elizabeth Brill: We are trying to promote it across the country for VA and non-VA clinicians. We’ve done so much work to put this together, we think it’s a terrific product. The little fact sheets on each symptom are very easy for a clinician to use, even someone who’s not very familiar with long COVID. And so VA wants to share that across the country with all clinicians.

Tom Temin: What are the most common symptoms that might be treated by this approach? Do we know the hierarchy here?

Elizabeth Brill: The most common symptoms that we generally see are respiratory and cardiology-type symptoms such as fluttering heartbeat, or some of them would have to be measured in a clinic — heart function, and also diabetes development can be increased after COVID. That would have to be measured by laboratory tests.

Tom Temin: So there could be a dietary component then, in the whole health approach, especially when you mentioned diabetes.

Elizabeth Brill: Absolutely. Dietary, and also exercise are both important components of whole health.

Tom Temin: But if you feel you have long COVID, then and you are a veteran, don’t live with it. There’s some help you can really get now.

Elizabeth Brill: Yes. And we have a veteran-facing guide, which asks the veteran questions that they can make notes to themselves and take to their clinician and share what their symptoms are so that they can get pointed in the right direction, in terms of specialty referrals.

Tom Temin: Dr. Elizabeth Brill is the deputy assistant undersecretary for health and clinical services at Veterans Affairs. Thanks so much for joining me.

Elizabeth Brill: Thank you so much.

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