Covid long-haulers

Written by  //  April 20, 2021  //  Health & Health care, Public Policy  //  1 Comment

COVID Long-Haulers Support Group Canada (Facebook)
Body Politic COVID-19 support group
Mayo Clinic: COVID-19 Long-term effects

15 October 2020 – Updated 1 March 2021
The tragedy of the post-COVID “long haulers”
(Harvard Medical School) Suppose you suddenly are stricken with COVID-19. You become very ill for several weeks. On awakening every morning, you wonder if this day might be your last.
And then you begin to turn the corner. Every day your worst symptoms — the fever, the terrible cough, the breathlessness — get a little better. You are winning, beating a life-threatening disease, and you no longer wonder if each day might be your last. In another week or two, you’ll be your old self.
But weeks pass, and while the worst symptoms are gone, you’re not your old self — not even close. You can’t meet your responsibilities at home or at work: no energy. Even routine physical exertion, like vacuuming, leaves you feeling exhausted. You ache all over. You’re having trouble concentrating on anything, even watching TV; you’re unusually forgetful; you stumble over simple calculations. Your brain feels like it’s in a fog.
Your doctor congratulates you: the virus can no longer be detected in your body. That means you should be feeling fine. But you’re not feeling fine.
How common are lingering COVID symptoms?
Tens of thousands of people in the United States have such a lingering illness following COVID-19. In the US, we call them post-COVID “long haulers.” In the United Kingdom, they are said to be suffering from “long COVID.”
Published studies (see here and here) and surveys conducted by patient groups indicate that 50% to 80% of patients continue to have bothersome symptoms three months after the onset of COVID-19 — even after tests no longer detect virus in their body.
Which lingering symptoms are common?
The most common symptoms are fatigue, body aches, shortness of breath, difficulty concentrating, inability to exercise, headache, and difficulty sleeping. Since COVID-19 is a new disease that began with an outbreak in China in December 2019, we have no information on long-term recovery rates.

Learning to breathe: German clinic helps COVID long haulers
(AP) Therapists at the clinic initially focus on stabilizing patients’ breathing. Then they work to restore stamina and motor coordination with the help of occupational therapy and posture training. Cognitive therapy and psychological support are also part of the program.
Similar clinics for “long haulers” have sprung up around the world over the past year, including in the United States. In Germany, such treatment is increasingly being offered by the country’s network of more than 1,000 medical rehabilitation centers, 50 of which specialize in pulmonary diseases.
“That doesn’t exist in many other countries yet,” Frommhold said.
It is unclear how many people suffer from long-term COVID-19, partly because the condition isn’t clearly defined yet. Scientists are still trying to understand what is behind the wide range of symptoms patients report.

5-7 April
People are losing their taste and smell to covid-19. Now there’s a cookbook to help.
Ryan Riley is a British chef who has spent the past several months concocting an array of science-based recipes to help covid “long-haulers,” whose sense of taste and smell disappears for nearly a full year because of the disease caused by the coronavirus.
Study suggests vaccines may improve symptoms for some COVID-19 long-haulers
Small U.K. study says 23% of vaccinated ‘long COVID’ patients saw symptoms reduce post-vaccination
(CBC) More than a year into the pandemic, it’s not clear how many people are experiencing long-term health issues after having COVID-19, but their numbers are growing.
Researchers think around 10 per cent of people who get sick with COVID-19 continue to live with lasting symptoms — some suggest the number could be as high as 30 per cent — which could mean millions worldwide are coping with some lingering issues from the disease.
Dr. Daniel Griffin, an infectious diseases physician at Columbia University in New York, said around 40 per cent of the patients he is treating for lingering health issues from COVID-19 are reporting either complete, or significant, improvement in their symptoms after being fully vaccinated.
He said the numbers in the U.K. study were “pretty on-target” with what he initially observed in his own patients, but that the impact seemed to bump up a couple weeks after people got their second dose.
Some COVID-19 Long Haulers Say Symptoms Improved After Getting Vaccine
(CBS Boston) Dr. Mallika Marshall says there are anecdotal reports that persistent symptoms in patients who have had COVID-19 get better within a few weeks of getting a vaccine, including fatigue, brain fog, shortness of breath, rashes, and diarrhea.
Right now, there isn’t enough scientific evidence to say that the vaccines are, in fact, responsible for the improvements, but this will be studied more closely.
The theory is that some patients with long-haul symptoms haven’t been able to completely clear the virus and that the vaccine gives them the immune boost needed to do so.

1 April
A year into pandemic, long-haul COVID-19 sufferers still struggle to get care
(CBC) Researchers have estimated that about 10 per cent of people who contract COVID-19 develop long-haul symptoms — some believe the number could be as high as 30 per cent —  but they still don’t understand why.
As provincial and federal governments focus on urgent pandemic priorities — from prevention and vaccination to caring for acutely ill patients in hospitals — people suffering debilitating symptoms in the aftermath of their COVID-19 infections are being left behind when it comes to pandemic-related planning and spending, some experts say.

8 March
Unlocking the Mysteries of Long COVID
A growing number of clinicians are on an urgent quest to find treatments for a frighteningly pervasive problem. They’ve had surprising early success.
(The Atlantic April edition) …more than 90 percent of the patients the center has seen—was a puzzling group “where we couldn’t see what was wrong,” Chen said. These tended to be the patients who had originally had mild to moderate symptoms. They were overwhelmingly women, even though men are typically hit harder by acute COVID‑19. (Acute COVID‑19 refers to the distinct period of infection during which the immune system fights off the virus; the acute phase can range from mild to severe.) And they tended to be young, between the ages of 20 and 50—not an age group that, doctors had thought, suffered the worst effects of the disease. Most of the patients were white and relatively well-off, raising concern among clinicians that many people of color with ongoing symptoms were not getting the care they needed.
… If there is any reason for hope in the growing epidemic of long COVID, it is that some academic medical centers are taking these patients seriously and tailoring treatment to them. Medicine’s history with hard-to-identify chronic illnesses, particularly those that mainly affect women, has not been a good one. For decades now, marginalized patients who have felt mysteriously unwell—with ME/CFS, with post-treatment Lyme disease syndrome, with Ehlers-Danlos syndrome, and more—have banded together into activist groups to try to legitimize their suffering. The same is happening online in the long-hauler groups, which are full of patients who have been met with disbelief by local physicians. But the Mount Sinai doctors (along with collaborative teams in various other academic centers) have responded promptly to the problem. Recently, the NIH and the World Health Organization recognized long COVID as a syndrome that warrants more research.

25 February
WHO urges actions for ‘long COVID’ sufferers
(AP) The World Health Organization’s Europe unit is reporting that about one in 10 people who contracted COVID-19 continue to show “persistent ill health” 12 weeks after infection.
Dr. Hans Kluge, the head of WHO Europe, says much about so-called “long COVID” remains unknown, but the “burden is real, and it is significant.”
In a policy brief released on Thursday, WHO Europe urged policymakers to do more to acknowledge and treat long COVID, which can bring severe fatigue, chest pain, heart inflammation, headache, forgetfulness, depression, loss of smell, recurrent fever, diarrhea and ringing in the ears.
It said available data showed that about one in four people with COVID-19 show symptoms about a month after testing positive, while one in 10 experience symptoms after 12 weeks.
Don’t call us ‘recovered’: COVID long-haulers say official stats ignoring them
‘A large percentage of this cohort of “recovered” people is still suffering. Calling them “recovered” is inaccurate, misleading and insensitive’

19-22 February
The hidden face of COVID-19: A growing number in it for the long haul
Those left suffering ask: Why is this happening? When will it end? Where can I get help?
(Montreal Gazette) Montreal’s first post-COVID clinic opened last week at the Montreal Clinical Research Institute on Pine Ave. (Those interested in booking an appointment can find information online at, by phone at 514-987-5581 or by email at [email protected]) Another was started in Chicoutimi, just before the Christmas holidays.
Dr. Alain Piché opened a post-COVID clinic last May at the Hôtel-Dieu Hospital in Sherbrooke. The first of its kind in Quebec, it has received 250 patients to date, roughly 30 per cent of whom experienced persistent symptoms like fatigue, muscle soreness and shortness of breath a month after they first tested positive. Of that group, half still had symptoms after six months. Blood samples will be taken regularly for the next two years and stored with the Québec COVID-19 Biobank. The samples will be used to investigate why some patients develop long-term symptoms and what the risk factors are. The clinic in Montreal, too, is conducting a similar study.
Almost a third of people with ‘mild’ Covid-19 still battle symptoms months later, study finds
By Dr. Sanjay Gupta, Chief Medical Correspondent
(CNN) More than a year into the pandemic, what has become abundantly clear is that SARS-CoV-2 — the virus that causes Covid-19 — is a tricky virus: Some people aren’t aware they’re infected at all, while others are hospitalized and some die. And a growing group of people get sick and then never fully recover. In support groups, they sometimes refer to themselves as long-haulers; their condition is alternately called long Covid, continued Covid, post-Covid syndrome or post-acute Covid syndrome.
Nobody is sure what percentage of people who’ve been infected with SARS-CoV-2 go on to develop post-Covid syndrome.
A new research letter published Friday in the journal JAMA Network Open is shedding new light on the condition. Researchers from the University of Washington followed 177 people with laboratory-confirmed SARS-CoV-2 infection for up to nine months — the longest follow-up to date. Notably, this group included 150 outpatients, who had “mild” disease and were not hospitalized.

17 February
Opera Singers Help Covid-19 Patients Learn to Breathe Again
A six-week program developed by the English National Opera and a London hospital offers customized vocal lessons to aid coronavirus recovery.
(NYT) Called E.N.O. Breathe and developed by the English National Opera in collaboration with a London hospital, the six-week program offers patients customized vocal lessons: clinically proven recovery exercises, but reworked by professional singing tutors and delivered online.

11 February
English National Opera develops program to help COVID-19 long haulers (video)
(Global news) The English National Opera has developed a pilot program, ENO Breathe, to help COVID-19 survivors strengthen their damaged lungs. Crystal Goomansingh takes you to one of the virtual lessons to explain how it works.
ENO Breathe
A breathing and wellbeing programme developed specifically for people recovering from COVID-19, who are still suffering from breathlessness and associated anxiety. Delivered by ENO in collaboration with Imperial College Healthcare teams entirely online, the programme focuses on breathing re-training through singing.
No prior experience or interest in singing is required to take part in ENO Breathe.
ENO Breathe is not a choir or singing group. It is a social prescribing (non-clinical) intervention that uses singing techniques to aid recovery from COVID-19.

8 February
London poised to lead research on toll facing COVID ‘long-haulers’
(London Free Press) London [ON] could become a leader in studying the long-term health impacts of COVID-19, the head of one of the city’s research institutes says, as focus intensifies on fallout of the disease in patients.
As the London area moves past the peak of the second wave, the city’s health research sector could play a major role in understanding the long-term impact of the disease and treating COVID-19 long-haulers, people who struggle with lingering symptoms, the head of Lawson Health Research Institute says.
“Where I think we really can make an impact is the long-term follow-up with patients who had COVID-19,” said David Hill, scientific director at Lawson, the research arm of London’s hospitals.
“There’s plenty of scope now for following these patients, probably for a number of years, to see what the long-term health implications are. . . . Because we have research groups in all of the chronic diseases, we’re well-positioned to do long-term follow-up with these patients.”

5 February
Why we haven’t cracked the mystery of COVID ‘long-haulers’ (video)
(PBS Newshour) “Long-haul” COVID, long COVID, post-COVID: it’s an illness still without an official name. But for people whose COVID-19 symptoms linger for months, the effects can be devastating and debilitating. Their symptoms range from the mundane to the bizarre: brain fog, shortness of breath, fatigue, tremors, tooth loss, racing heart, glaucoma, among others. In this episode of “America, Interrupted,” PBS NewsHour correspondent Stephanie Sy talks with three “long haulers” about their experiences battling this mysterious illness, and Dr. William Li, a vascular biologist who is trying to unravel this medical mystery through his research.
[Here’s What a Harvard Cancer Doctor Eats Daily to Prevent Disease
Dr. William Li spoke with us on what he eats every day to not only stay healthy but fight off chronic diseases like cancer and diabetes; also check out his Fb page]

31 January
COVID-19 clinics for ‘long haulers’ aim to treat patients stuck in limbo
(CTV Vancouver) Researchers around the world are trying to unravel the mystery of so-called long COVID to help patients afflicted with an assortment of debilitating symptoms, though they are typically excluded from statistics related to COVID-19 or considered recovered. Some, like Graves, were diagnosed with COVID-19 by their family doctors based on symptoms, not a positive test, in the early days of the pandemic when testing was not offered widely.
“We didn’t recover. We survived,” said Graves, who was referred to a clinic where “long haulers” are treated and studied in order to better understand the cause of their ongoing illness while others recover within a few days or don’t have any symptoms at all.
Graves said she has so far had a virtual appointment with a general internist at a clinic at St. Paul’s Hospital, which is part of a network of three sites in the Vancouver area and is believed to be the only such provincially funded initiative in Canada.

30 January
Nearly $8 million donated to mental health as part of 11th annual Bell Let’s Talk Day
(National Post) This year’s campaign was different, and more critical, than ever because it had to take the impact of COVID-19 into account.
“40 per cent of Canadians feel that their mental health has worsened since COVID, and people who already had issues say their mental health has gotten worse. So, we’re seeing an increased demand for services in a system that was already struggling.”

28 January
‘The tip of the iceberg’: COVID long-haulers facing financial ruin
(Ottawa Citizen) By some estimates, there are tens of thousands of Canadians who suffer lingering after-effects from COVID-19. In some cases, they never knew they were initially infected, or had a mild infection, but suffer ongoing long-term symptoms. Sometimes,…the symptoms are severe enough to prevent them from functioning the way they did before the illness.
…the lack of government support for people in [this] situation is creating a socioeconomic crisis “and no one is paying attention.”
Canadian researchers are studying the long-haul phenomenon, but Renaud said Canada is behind some other countries in recognizing it and supporting patients. In the UK, there are dozens of post-COVID care clinics. Late last year, the UK produced official guidelines for the management of long COVID.
…long COVID can be difficult to diagnose, which can make it harder to get medical help or support.
…some long-haulers face obstacles getting diagnosed and there are no established protocols about how it should be treated.
Long COVID leaves patients and researchers in a maze of questions
Millions of COVID-19 survivors worldwide — even those who had mild illness — are reporting long-term symptoms months later, including brain fog, persistent exhaustion, and lung, heart or kidney damage, Axios’ Eileen Drage O’Reilly writes.
Why it matters: For too long, these long-haulers, as they call themselves, have not been taken seriously enough by providers and researchers, some doctors tell Axios, adding that there’s an urgent need for dedicated research in order to treat patients with lingering symptoms.
Doctors started to realize long COVID was a problem last spring, and yet “there’s little to show for it,” says cardiologist Eric Topol, founder and director of Scripps Research Translational Institute. “I’m very disheartened about how poor the attention has been to this.”
What’s happening: Many providers and health care systems initially dismissed the symptoms as related to something else, but growing evidence points to SARS-CoV-2 as the culprit in many cases.
• A study published in The Lancet looked at people who had severe COVID-19 illness in China and found that six months later, 75% continued to experience at least one symptom.
• A preprint study in medRxiv, not yet peer reviewed, surveyed 3,762 self-described long-haulers from 56 countries, with symptoms after the onset of what was likely COVID-19. Six months after first becoming sick, almost half were unable to work full time and 22% weren’t working at all. 88% had cognitive dysfunctions or memory loss, and most had multiple symptoms.
• Fragments of SARS-CoV-2 have been found in multiple organs, and the Mayo Clinic reports they’ve seen frequent complaints of long-term persistent headaches, loss of smell (anosmia) and taste (ageusia), and trouble sleeping.
• Mayo found some patients had organ damage, including injured heart muscle, causing myocarditis, palpitations and fast heartbeats; scarred lung tissue, leading to breathing problems; and neurological damage, causing brain fog, strokes, seizures and Guillain-Barre syndrome.
Between the lines: There are other viruses that either cause long-lasting symptoms, such as Epstein-Barr, or stay in the system where they can reactivate and trigger later complications, like varicella-zoster.
• It is unknown if SARS-CoV-2 can hide in the system, but a recent, early study of animals in the journal Viruses indicates this could be a possibility.
• The cause of long COVID needs to be discovered before targeted therapies can be made, says Neha Dangayach, director of neuroemergencies management and transfers for the Mount Sinai Health System.
• “Is it a reactivation of the virus? Is it an immunological response or a persistent immunological response to the initial viral exposure? Or is it a recirculation of the viral particles that trigger some of these symptoms?” Dangayach asks.
There are also many questions about why some people develop long COVID-19 and others don’t.
• “Why you, and not me? Why do [some] 80-year-old people who get COVID die, and some survive? Why do some 20-year-old people who get COVID need a double lung transplant, whereas 90% of all the others have no symptoms? We don’t know,” says Igor Koralnik, chief of neuro-infectious diseases and global neurology at Northwestern Memorial Hospital, who started a long COVID clinic in May.
• Topol says they need to figure out whether early treatments like monoclonal antibodies may help diminish the chance of long COVID.
What’s next: Long COVID is becoming a higher priority, and several longitudinal studies are expected to come out soon, Dangayach says.
• In the U.S., Congress has set aside some funding for research and NIH is studying the issue, NIH director Francis Collins says.
• Long-haulers are urged to seek specialized clinics, join support networks and consider sharing data in this patient-led survey.
• While there aren’t enough overall, there are a growing number of interdisciplinary clinics popping up around the country to try to address the myriad problems associated with long COVID.

27 January
10 months later, this COVID-19 ‘long-hauler’ is still experiencing symptoms
‘Are we going to get better eventually?’ Susie Goulding asks
Still today, 10 months after Susie Goulding fell ill with the first symptoms of what eventually could only be identified as COVID-19, she struggles to find the right words to complete her sentences.
As she pauses to think of the right term, Goulding explains that two recent neuroimaging tests on her brain found that some areas of her cognitive function are currently operating at only 5 per cent.
The once-active, on-the-go, Oakville resident said she also has issues performing any kind of physical activity, as the exertion is too much for her body to handle. But these are only two of many complications that have been lingering for months.
After months of receiving little to no answers, Goulding started a Facebook support group in June, now called COVID Long-Haulers Support Group Canada, which currently has over 11,000 members.
Since then, Goulding has been connecting with thousands of other Canadians who have experienced and continue to experience a long list of symptoms for which they cannot get a clinical diagnosis, as their window for COVID-19 testing has long passed.
Goulding said the symptoms run the gamut, from chronic fatigue to gastrointestinal issues, tingling and numbness in limbs, headaches and loss of vision and loss of appetite. Some long-haulers reported experiencing more serious issues, like strokes, micro brain bleeds, and liver and kidney issues.
One of the most frustrating aspects of dealing with these symptoms, Goulding said, is that medical professionals are only in the beginning stages of collecting data and do not have many answers for her. She also doesn’t know if any of this damage is permanent.

21 January
What If You Never Get Better From Covid-19?
Some patients could be living with the aftereffects for years to come. Recent research into another persistent, mysterious disease might help us understand how to treat them.
(NYT) Zijian Chen estimates that about 10 percent of Covid-19 patients end up developing symptoms that persist for months and months — a number that would equate to roughly 100,000 chronically sick people in New York State alone. Some surveys suggest the number is higher. A study from Ireland found that more than half of Covid patients, whether they’d been hospitalized or not, reported fatigue 10 weeks out; nearly a third hadn’t returned to work. In another study, from the Faroe Islands, about half the patients with mild cases had at least one symptom 18 weeks later. A third, much larger study, from China, reported that three-quarters of those patients who were hospitalized with Covid-19 and then discharged still experienced at least one symptom six months later.
My ‘Long Covid’ Nightmare: Still Sick After 6 Months
A Times reporter caught the coronavirus during the New York City outbreak last April. But the acute phase of the illness was just the beginning.

14 January
A possible model?
When it comes to mental health, now more than ever, every action counts.
Kids Help Phone is just one of the many beneficiaries of Bell Let’s Talk, a wide-reaching program designed to break the silence around mental illness and support mental health all across Canada.
Whether by phone, text, mobile app, Facebook messenger, or through the website, Kids Help Phone is always open, in any moment of crisis or need.
“Anxiety, stress and depression account for more than half of what people are reaching out to us about. We’re having big dialogues around isolation, and with that, comes dialogues around grief and loss of normal life,” said Hay.
“Family stress is rippling through all our conversations, and calls about abuse have gone up around 16 per cent, which makes sense, since a lot of the services where they might have gone before are now closed.”


29 December
The Problem of ‘Long Haul’ COVID
More and more patients are dealing with major symptoms that linger for months
(Scientific American) “Over the past few months evidence has mounted about the serious long-term effects of COVID-19,” said the World Health Organization Director-General, Tedros Adhanom, at an international long-COVID forum on December 9. At the same event, Danny Altmann, an immunologist at London’s Imperial College, said that his “guesstimate is that we probably have way more than five million people on the planet with long COVID.” The worldwide percentages of infection suggest that many of those people are living and suffering in the U.S.

22 December
Canadian researchers looking into COVID ‘long-haul’ effects
Angela Cheung and Margaret Herridge are co-leads of the study that aims to “try to understand what it means to be a long-hauler” – a COVID-19 survivor who is suffering long-term symptoms

14 December
Long-Haul COVID-19 May Be a Public Health Crisis After the Pandemic
The National Institutes of Health sponsored a meeting this month to discuss the long-term symptoms of the coronavirus.
Experts shed light on the millions of people around the world who have been affected by lingering symptoms from COVID-19.
Some patients have been exhibiting symptoms for more than 4 weeks, or even months, after “recovering” from COVID-19.

9 December
The Long Haul
Covid-19 was originally thought to be a quick disease. The virus came, did its damage, and, for those who survived, was gone in a month or so. But new research suggests that it can linger much longer than anyone thought. These seven survivors are living proof
(Toronto Life) Who she is: Amara Possian, 31
“I returned to work in mid-June, just two or three days a week, and quickly noticed some concerning symptoms. I was unable to come up with ideas or think straight. I’m a pretty good proofreader, but one time, I reviewed an email and thought it was ready to send. Then I reread it 10 minutes later and caught so many glaring mistakes. Sometimes I would read over something I just wrote and there would be an entire chunk of a sentence missing. Or I would message somebody on Slack about something pretty straightforward, and when it became clear they weren’t understanding me, I would read back what I wrote and realize it made no sense. It was really unsettling.”

29 October
Long-Hauler Syndrome: What We Know About Post-Covid Symptoms, Explained By a Top Disease Expert
by Rachael Ray Show Staff
One of the scariest aspects of Covid is that it seems to affect everybody differently. Some people get severe symptoms, others are asymptomatic and may never realize they have it — and now, doctors and scientists are seeing that some Covid patients who have seemingly recovered are experiencing lingering, long-term symptoms months later. Have you seen “Long-Hauler Syndrome” in the headlines? That’s what we’re talking about.
Here to answer our questions about the syndrome is Dr. William Li, internal medicine physician, research scientist and author of Eat To Beat Disease — who’s currently at the forefront of Covid research.

8 October
Ontario man who’s suffered months of COVID-19 symptoms: ‘I don’t even feel like I’m in my own body’
(Global) Lawson is one of a number of people who have experienced COVID-19 symptoms for weeks and months after testing negative for the novel coronavirus. … Lawson said he wants people to recognize the COVID-19 long-haulers. Since his diagnosis, he’s joined a Facebook group of Canadians who are still experiencing coronavirus symptoms weeks or months after they’ve been infected.

One Comment on "Covid long-haulers"

  1. Diana Thebaud Nicholson February 26, 2021 at 2:34 am · Reply

    From Amara Possian: “I’ve found [the Body Politic COVID-19 support group] really helpful for understanding what’s happening and how to cope (in case you want to add a link to that too”
    Body Politic started the COVID-19 support group after Founder and EIC Fiona Lowenstein, and Creative Director Sabrina Bleich became sick with coronavirus in early March. After falling ill, we quickly realized that there was not enough online content or resources dedicated to people struggling with coronavirus. As we scrolled through Instagram feeds filled with tips on navigating boredom during quarantine, or how not to catch the virus, we felt increasingly isolated, misunderstood, and ignored. With news of infection rates rising, we knew a community of people like ourselves existed, and was growing – we just needed a way to reach each other. Since our launch, we’ve had over 18,000 people sign up to join the group, and have migrated platforms to Slack to accommodate the growth and allow for small discussion channels based on community or topic. Our group consists of people from all over the world who have tested positive, are experiencing symptoms, or are recovering from COVID-19. Our discussion groups includes 50+ channels for based around different communities and topics. Some of our channels include one for those symptomatic for 30+ days or 90+ days, caretakers of sick friends or relatives, those who have recovered from being on ventilators, those experiencing known and lesser known symptom groups such as respiratory, neurological, GI, and others, and forums to discuss mental health, financial and employment concerns, medical advocacy, along with many others.

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