Long COVID isn’t just “feeling a bit tired” – for many South Africans, it’s a life-altering struggle with exhaustion, anxiety, and memory problems that simply won’t go away. And this is the part most people miss: even when the infection is long gone and the tests are “normal,” their minds and lives still feel completely different.
The lingering impact of long COVID
Four years after the peak of the COVID-19 pandemic, doctors across South Africa still hear the same unsettling line: “I feel better, but my mind isn’t the same.” People who once bounced back quickly from illness now find themselves stuck with a strange mix of brain fog, low energy, and emotional distress that they can’t easily explain. What started as a virus attacking the lungs has, for some, become a long-term condition affecting how they think, feel, and live day to day.
South Africa recorded more than 4 million confirmed COVID-19 cases, and for many people, physical recovery was only the first step. Instead of returning to normal, they developed persistent fatigue, difficulty concentrating, and mood changes that disrupted their work, relationships, and overall quality of life. These ongoing problems are often grouped under the term “long COVID,” and for some, the mental and cognitive symptoms are a major part of that picture.
Why a South African study was needed
Most of what the world knows about long COVID comes from studies in wealthier countries in Europe and North America. That means African populations – with different age profiles, health backgrounds, and living conditions – have often been left out of the story. Yet these differences can strongly influence not only who gets sick, but also how people recover and what kind of long-term effects they experience.
A team of specialist psychiatrists, clinical immunologists, and laboratory scientists at the University of Cape Town wanted to close this gap. They set out to understand why some South Africans continue to struggle with fatigue, anxiety, and memory issues long after their initial infection. They were especially interested in whether the body’s early immune and cardiovascular responses to the virus – essentially, how the body fought COVID-19 in the beginning – could help predict who might later develop long-lasting neuropsychiatric symptoms.
A worrying picture from Cape Town
Their recent research in Cape Town painted a troubling picture: more than half of the people who had been infected with the coronavirus – most of whom had been hospitalised – still had at least one mental or neurological symptom more than six months after infection. These symptoms included overwhelming tiredness, difficulties with concentration, or problems with memory, and in many cases they had not resolved even two years later.
Perhaps the most striking finding was that these symptoms were new. The people affected were not simply noticing old issues more; they reported that these problems began only after having COVID-19. Yet despite the clear impact on their daily lives, standard medical tests offered few answers.
What the researchers actually did
To dig deeper, the team followed 97 people in Cape Town who tested positive for SARS-CoV-2 during the first three waves of infection, before vaccines were widely available. Most had moderate to severe illness and required hospital care, but some had only mild symptoms or none at all. These waves occurred roughly from June to August 2020, November 2020 to February 2021, and May to September 2021.
Blood samples were taken while participants were at their sickest and then again months later, between 6 and 24 months after infection. Using advanced protein analysis, the researchers measured 96 different molecules related to inflammation, cardiovascular stress, and the renin–angiotensin system – a hormone system that helps regulate blood pressure and has been tied to how COVID-19 affects the body.
How symptoms were tracked over time
At least six months after infection – and for some, up to two years – participants were interviewed by phone using standardised, validated questionnaires. These tools measured levels of anxiety, fatigue, and cognitive function. One of the main tools used was the Telephonic Montreal Cognitive Assessment, which screens for issues with memory, attention, and thinking.
There was no separate control group interviewed for comparison, but the researchers could draw on known background rates for people of similar age. This helped them distinguish between what might be expected in the general population and what appeared to be linked to past COVID-19 infection.
Key findings: symptoms that don’t fade away
The results were hard to ignore:
- Persistent symptoms were common: More than half of the participants had at least one ongoing symptom more than six months after infection.
- Memory and thinking problems were frequent: About 44% showed measurable cognitive or memory impairment on testing, and 53% reported noticeable memory issues in their daily lives.
- Fatigue was widespread: Around 55% described moderate to severe fatigue, the kind that makes even routine tasks feel exhausting.
- Anxiety and emotional distress increased: Roughly one in four participants had high levels of anxiety, and the number of people taking psychiatric medication nearly doubled compared with before their infection.
One of the most revealing – and potentially controversial – findings was that the severity of the original illness did not reliably predict who would struggle later. These long-term problems appeared in people across the spectrum, including those who had never been hospitalised and might be assumed to have had a “mild” case. This challenges the comforting belief that only the very sick are at risk of long COVID.
The biomarker mystery: tests that don’t tell the story
The researchers also hoped that blood biomarkers – objective signs of what is happening in the body – might point to who was at risk. They looked at markers related to inflammation, cardiovascular strain, and the renin–angiotensin system, both during the acute illness and during recovery.
But here’s where it gets controversial: none of these biomarkers were linked to the later development of cognitive or mental health symptoms. In other words, the blood tests that might normally help doctors identify high-risk patients simply did not help predict who would go on to develop long COVID–related brain fog, fatigue, or anxiety. For patients, this can be deeply frustrating – they feel terrible, yet their test results often look “normal.”
What might be happening in the brain?
The lack of a clear biological predictor suggests that long COVID’s mental and cognitive effects are not easily explained by inflammation alone. Some researchers think the virus may directly damage brain cells or linger in the nervous system, causing ongoing subtle injury. Others suspect that long-lasting activation of immune cells in the brain – often called microglial activation – may be part of the puzzle.
None of these ideas has been fully proven, but together they highlight that the brain can be affected in ways that don’t always show up on routine blood tests. This raises an uncomfortable question: if standard tests can’t capture what patients are experiencing, do health systems need new tools – and perhaps a new mindset – to take these symptoms seriously?
The added burden of South Africa’s realities
In South Africa, the story of long COVID cannot be separated from the social and economic realities of the country. Even before the pandemic, high unemployment, deep inequality, and uneven access to healthcare created conditions of ongoing stress. The pandemic only intensified these pressures.
Studies conducted during lockdown periods found rising rates of domestic violence and psychological distress, especially among people with lower incomes and fewer resources. When these stressors collide with long-term symptoms like fatigue and memory problems, the mental and emotional toll of COVID-19 becomes even heavier. It is not just about a virus; it is about how illness interacts with existing social vulnerabilities.
How this fits with global evidence
The Cape Town findings are consistent with research from other parts of the world showing high rates of cognitive and emotional symptoms months after infection. A large global review has estimated that roughly one in five people experience persistent issues such as fatigue, depression, anxiety, or memory problems six months after having COVID-19.
What makes the South African study stand out is that it is one of the first from the continent to combine early blood-based biomarker data with long-term mental and cognitive follow-up. Despite clear differences in demographics and healthcare systems, the pattern looks similar to that seen in other regions: many people end up with long-lasting symptoms, but there is still no simple laboratory test that can reliably predict who they will be.
Beyond biology: a biopsychosocial view
Because of this, the researchers argue that it is essential to look beyond blood tests and adopt a broader biopsychosocial perspective. This approach recognises that health is shaped not just by biology, but also by psychological factors (like stress, coping skills, and past trauma) and social conditions (such as income, housing, and community support).
Long COVID is not purely a biological condition; it is a human experience at the intersection of the body, mind, and society. Two people with similar infections may have very different recoveries, depending on their mental health history, support systems, and daily stresses. Ignoring this wider context risks oversimplifying a complex and deeply personal condition.
What needs to happen next
The study highlights several important steps for improving long COVID care:
- Acknowledge long COVID as real and disabling: Symptoms like fatigue, brain fog, and anxiety might not show on scans or blood results, but they can completely derail a person’s ability to work, study, or manage family responsibilities.
- Screen early in primary care: Short, validated questionnaires can help frontline clinicians pick up on cognitive or mental health problems that patients may struggle to describe or might dismiss as “just stress.”
- Build multidisciplinary teams: Collaboration between general doctors, psychiatrists, psychologists, neurologists, and occupational therapists can give patients a more holistic route to recovery, addressing both mental and physical aspects.
- Develop and fund follow-up services: Dedicated long COVID or rehabilitation clinics can support people over months or even years, helping them gradually regain function and confidence.
- Keep focusing on prevention: Vaccination and infection control measures remain key tools for reducing the risk of long COVID in the first place. One important limitation of this particular study is that it involved people infected before vaccines were widely available. Other research suggests that vaccination may lower the overall prevalence of long COVID at the population level.
Living with a changed sense of self
For many people, “recovery” from COVID-19 is not simply a matter of testing negative or leaving the hospital. It is about slowly trying to reclaim a normal life in the face of lingering symptoms. Participants in the study often reported feeling “not themselves” for months. Some forgot words mid-sentence, struggled to stay focused at work, or felt drained no matter how much they rested.
These are not minor annoyances; they can shake a person’s confidence, threaten their livelihood, and erode their sense of identity. When someone can no longer think as clearly or work as effectively as before, it affects not only their income but also how they see themselves and their place in society.
A call for empathy and open debate
The stories behind the data make one thing clear: long COVID is not just a medical label. It is a lived reality that deserves empathy, sustained research, and serious public health attention. But here’s where it gets controversial: if there is no clear biomarker and symptoms vary so widely, how should health systems define, diagnose, and support long COVID? Should someone’s subjective experience be enough to unlock support, even when their tests look normal?
This raises questions that do not have easy answers – and that’s exactly why public discussion matters. Do you think health services are doing enough for people with long COVID, especially when their lab results don’t “prove” anything? Should governments invest more heavily in long-term rehabilitation, even as some argue the pandemic is over? And if you or someone you know has faced these lingering symptoms, what do you believe doctors and policymakers are still getting wrong?
Share your thoughts: Do you see long COVID as one of the biggest unfinished chapters of the pandemic, or do you think its impact is being overstated? Your perspective – whether you agree or strongly disagree – can help shape how societies choose to respond next.
