Doctors used to swear by convalescence, a slow recuperation time. Some specialists believe that reintroducing it could help with a variety of long-term ailments and injuries.
Hosanna Krienke, a Ph.D. student, was seeking themes for her dissertation on British literature in 2012. As a cancer patient in remission, she was impressed by the repeating subject of illness and recovery in nineteenth-century fiction. Despite the fact that Krienke had recently completed immunotherapy treatment, she still felt like a patient. Everyone else acted as if it were all done, “and I couldn’t describe why I didn’t feel the same.”
Why did characters in classic Victorian novels, from Charles Dickens’s Bleak House to Francis Burnett’s The Secret Garden, feel free to spend so much time improving, Krienke wondered? And why is it that individuals nowadays are expected to recover rapidly after a terrible sickness or injury?
She discovered that shifting attitudes about healing was the answer. Prior to the introduction of modern medical care in the twentieth century, humans were vulnerable to a variety of infectious diseases ranging from typhoid to tuberculosis. Those who were fortunate enough to survive infection were likely to recover slowly, according to Krienke. This restoration process—the transition from acute sickness to full health—was a key priority for clinicians and families. For centuries, convalescent care was accompanied by its own set of beliefs and rules designed to avoid relapse and integrate patients back into normal life.
However, as medical technology advanced, people’s tolerance for prolonged recovery diminished. “Modern medicine is uncomfortable dealing with problems for which there is no quick answer,” says Lancelot Pinto, consultant pulmonologist at Mumbai’s P.D. Hinduja Hospital and Medical Research Center. “When there were no remedies, patients were left to live out the natural history of the disease. There is no wiggle room for disorders that now have a solution; it is assumed that if you are treated microbiologically if the tests come back normal, you don’t deserve any more rest… and that the symptoms could be imagined or psychological in nature.”
Now, academics like Krienke, who studies literary and medical history, believe that ancient concepts about recovery could give vital context for the epidemic, as millions of COVID-19 patients are disappointed by the persistence of symptoms for weeks or months after infection. “All kinds of illnesses have enduring repercussions, but we don’t have a method to talk about it culturally,” says Krienke, who is now an assistant lecturer at the University of Wyoming. “I believe convalescence is a useful paradigm for the present.”
Why do we require rest?
According to Sally Sheard, historian and executive dean of the Institute of Population Health at the University of Liverpool, the pandemic provides an opportunity to examine the patient’s experience, as well as the amount of time we are ready to allow for rehabilitation. “One of the most apparent lessons from my research on convalescence is that you can’t speed the process,” she says. In the United Kingdom, some COVID-19 patients were discharged too quickly to free up beds, while others were kept in the hospital for too long due to a lack of care at home, she says, adding, “therefore maybe we need midway or recovery homes,” similar to older convalescent facilities.
As scientists have a better knowledge of chronic COVID-19—a disease in which symptoms persist long after the initial diagnosis and illness—the epidemic has focused greater attention on long-term recovery. Many hospitals across the world, for example, have established post-acute care clinics for these patients. Pinto predicts that if medication for COVID-19 is discovered, “the office will want you back in five days,” but he also recognizes the possibility to advance understanding of long-term mechanisms in virus infections. Post-viral symptoms have been described in infections ranging from SARS to dengue, but they have received little attention.
“Dengue patients experience lethargy for several weeks after infection, and chikungunya patients can experience pain for months,” Pinto notes, “but we don’t talk about long dengue or long chikungunya.”
Hospitals haven’t seen “this raw number of people with a common condition in a century,” according to Ann Parker, pulmonologist and co-director of the Johns Hopkins Post-Acute COVID-19 team. In the absence of evidence-based therapies for protracted COVID-19—interventions that lengthier trials might provide—the clinic treats patients symptomatically, drawing on post-intensive-care rehabilitation in particular. According to Parker, treatment can involve “supportive” services such as physical therapy and counseling for symptoms such as weariness and worry. “We definitely notice that patients tend to improve,” she continues, despite the fact that there haven’t been any randomized trials comparing different therapies.
Many clinics began putting patients with persistent fatigue, the most frequent symptom, on exercise regimens as part of normal therapy early in the epidemic. However, in August, the American Academy of Physical Medicine and Rehabilitation issued a multidisciplinary consensus statement recommending individualized programs and advising patients to “pay attention to their body” and “pace” their activity—exactly like 19th-century prescriptions for convalescence.
Pacing is key because many patients suffer from “post-exertional malaise,” in which a burst of activity leads to exacerbated weariness, according to Alba Miranda Azola, co-director of Johns Hopkins’ Post-Acute COVID-19 Program and a statement co-author. “We have found that patients with post-viral fatigue that push through and enter a crash cycle have overall functional decline.” According to William Brode, medical director of the Post-COVID-19 Program at the University of Texas at Austin, cognitive demands can also cause a crash. He’s seen kids collapse for three days following the stress of a term paper deadline. “And they might not have even left the dorm room.”