According to the most recent estimates, more than 65 million people worldwide may be living with some form of long Covid, a startling number that will only continue to increase, given the lack of available treatment options. One of the scientists leading the race to try to unravel the complexities of long Covid is Akiko Iwasaki, an immunology professor at Yale School of Medicine. Iwasaki has been at the forefront of numerous research breakthroughs throughout the course of the pandemic, from understanding why men were more vulnerable to the Sars-CoV-2 virus, the autoimmunity that made some people unexpectedly susceptible, and why a small minority have experienced heart inflammation in response to the Covid-19 vaccines. Most recently, Iwasaki has been awarded the prestigious Else Kröner Fresenius Prize for Medical Research, worth €2.5m (£2.2m), in part due to her ongoing work on long Covid. Are we getting closer to understanding some of the causes of long Covid? Long Covid is a blanket term that likely describes multiple diseases with different causes. We still don’t have the answers, but there are some hypotheses that are becoming more likely and others less likely. There’s more evidence now showing either viral proteins or viral RNA in various tissues, months after infection. The hypothesis that long Covid symptoms could be caused by the reactivation of latent viruses such as Epstein-Barr virus is also gaining momentum. The other idea is that changes can occur due to the inflammation from an acute Sars-CoV-2 infection, both at the site of infection, and in distal organs such as the brain. We have a paper that we published last year which demonstrates that even a mild Sars-CoV-2 respiratory infection can result in long term changes in the brain. More than 200 symptoms have now been associated with long Covid, affecting almost every organ system in the human body. Many are also experienced by chronic fatigue syndrome (ME/CFS) sufferers. What similarities have been found in the biology of these two illnesses? One you’ve probably heard of is microclots, which appear to be happening in a large fraction of people from long Covid and potentially ME/CFS. These are tiny little clots in the blood that may be impairing oxygen exchange and other important functions of the circulation. The way blood oxygen is being utilised by tissues also appears to be impaired, which could be due to microclots as well as mitochondrial dysfunction. I always have in the back of my mind – how can these insights from long Covid help people with ME/CFS and other post-acute phases of infections, like post Lyme disease? I’m so excited about receiving this new award because it shows that long Covid and ME/CFS are diseases of global significance. It’s validation and acknowledgment for people who have been suffering for decades with ME/CFS, a disease that has been mostly ignored and completely understudied given the amount of suffering it has caused. What new treatment avenues are being explored for long Covid? We are starting a clinical trial where 50 patients will be treated with the antiviral drug Paxlovid and 50 will be given a placebo. This is to probe whether persistent virus infection may be causing long Covid in a subset of people. We’re not giving them the conventional five-day course, but a 15-day course of treatment, to see if that can eliminate the source of the problem, which is the remnants of replicating virus. You’re a prolific tweeter, with more than 200,000 Twitter followers. How important a platform is it for scientific communication? I didn’t plan to have so many followers! I now have to be even more careful what I say, and how I say things because it is very easy to be misinterpreted. But Twitter has been an incredible platform. Within seconds, people can read about the latest scientific findings, and what they mean. I also often learn from people who are posting their symptoms and what has helped them. I think it’s still very important for me to keep tweeting fact-based scientific content – there’s a lot of misinformation and disinformation out there. But there are some days where I feel like I don’t even want to open it. The unfortunate side is that there are a lot of trolls and abusive comments, sometimes people with extreme viewpoints that clash with mine, or those who still don’t believe that long Covid is real and think it’s all in people’s heads. You’ve also spoken about toxic environments in real life, particularly in academia, where you’ve called out issues of bullying and sexism. This is still a big problem. Somehow bullying and mistreatment of junior staff has never been punished. People just keep doing it, and they get promoted and receive grants. This bullying occurs because many professors hold so much power that goes unchecked. Students and postdoctoral researchers rely on their recommendation letters to get their next job, so they can essentially be held hostage. You’ve also mentioned how being a prominent woman of colour in science means that you have to endure a greater degree of toxic behaviour from other academics. Do you think there is a racism issue within the scientific community? I think so. It’s very masked and veiled so it’s hard to pinpoint but I definitely feel like I’m spending more time thinking about how to respond to an email, because of my background, because I’m a woman, and because I’m a person of colour. There’s a lot of finessing of the words and making sure it’s assertive enough but doesn’t sound offensive. This struggle, and one that I’m sure others are going through, is double the work. Another challenge is that you get asked to serve on every committee, because they need to make every committee diverse and equitable. I get that, but it just means more work for people like myself, and less time to spend on research. Earlier this month, the World Health Organization downgraded Covid-19 from the status of “emergency of international concern”, while the Biden administration has officially declared an end to the Covid-19 public health emergency. What is your perspective on this – could the pandemic still have some twists to come? I understand why the emergency declaration had to be ended, because of the economic impact and other things. But at the same time, we are not done with Covid, not even close. The virus is here to stay with us and that’s why we do need to think about future booster vaccines that match with the circulating variants, as well as the potential of new variants that further evade our existing immunity. I get that people want to move on from the pandemic, but the virus is still out there, people are getting infected, and there’s the possibility of developing long Covid. I’m still wearing masks and following preventive practices as much as possible.