Gaming With Long Covid

I fully expect that this week’s episode of Access-Ability is probably going to get suppressed by YouTube’s algorithm due to the topic I’m going to be discussing, and my unwillingness to discuss it in euphemistic language, so any likes, comments, shares, or subscriptions to my channel this week would be deeply appreciated.

We are now approximately three years into living in a world where we know that Covid-19 exists. We know how it spreads, and we know what its symptoms are in both the short term, and long term.

A primarily respiratory viral illness, Covid-19 in the short term can cause a fever, a persistent ongoing cough, loss or change in sense of taste and smell, shortened breath, fatigue, physical aches and pains, and other symptoms. In some cases its impacts can be more serious, leading to hospitalisation and even death.

While we’re now living in a world with availability of vaccinations, and testing, Covid-19 is still an ongoing threat to health. As the virus continues to mutate into new strains, vaccines lessen in effectiveness in preventing the spread of the disease over time, and while vaccination can lessen the effects of Covid once contracted, it doesn’t prevent all symptoms for infected individuals, with long term symptoms in particular able to still occur in vaccinated individuals who contract the virus.

So today, on Access-Ability, I’m going to be talking about some of the long term symptoms of contracting Covid-19, colloquially referred to as the symptoms of “Long Covid”, and how those symptoms can necessitate accessibility support when doing things like playing video games.

I’m going to talk about how common Long Covid symptoms are, how the symptoms are in many cases correct to be labelled as a disability, and how video games are going to have to increasingly take into account the needs of gamers with Long Covid as a group with accessibility needs of their own that are distinct, if we continue to live in a world where contraction of this virus becomes normalised.

So, to start of with, let’s talk a little bit about what Long Covid is, and who it impacts.

Long Covid is the name given to a series of Covid 19 symptoms that seem to, in some portions of the population, continue to persist after a person is no longer testing positive for the Covid-19 Virus. These symptoms can persist for a few weeks, a few months, or in some cases seemingly be permanent changes to a person after infection.

Symptoms of Long Covid include extreme tiredness and fatigue, persistent shortness of breath, long term loss of or change in sense of smell, muscle aches and pain, memory issues (often referred to as brain fog), heart palpitations, dizziness, joint pain, tinnitus, ear pain, and other similar symptoms.

While Long Covid certainly doesn’t affect every person who contracts Covid-19, that’s not to say that the condition is uncommon, far from it. According to a study titled “The prevalence and long-term health effects of Long Covid among hospitalised and non-hospitalised populations: a systematic review and meta-analysis”, “ 45% of COVID-19 survivors, regardless of hospitalisation status, were experiencing a range of unresolved symptoms at ∼ 4 months.”

To put that number into some perspective with a different context, according to a UK survey titled “Prevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK: 3 November 2022”, “An estimated 2.1 million people living in private households in the UK (3.3% of the population) were experiencing self-reported long COVID (symptoms continuing for more than four weeks after the first confirmed or suspected coronavirus (COVID-19) infection not explained by something else)”

The survey goes on to say that “Long COVID symptoms adversely affected the day-to-day activities of 1.6 million people (73% of those with self-reported long COVID), with 333,000 (16%) reporting that their ability to undertake their day-to-day activities had been “limited a lot”.”

“Fatigue continued to be the most common symptom reported as part of individuals’ experience of long COVID (70% of those with self-reported long COVID), followed by difficulty concentrating (45%), shortness of breath (42%) and muscle ache (42%).”

I know I’ve shared a lot of stats and data up front here, but I feel like it is important to make some of this information clear before we get into talking about video games. Even if we only look at the UK as a sample, 1.6 million people report that Long Covid has limited their ability to engage in day to day activities, and of that group many report symptoms that undoubtedly will impact their ability to, among other activities, play video games the way they may have done so in the past.

So, with that all said, let’s talk a little more in depth about some of those symptoms, and how they’re likely to impact people’s accessibility needs when playing video games.

Extreme Tiredness and Fatigue are an easy place to start, as those both impact the ability to play games that require ongoing focus and attention, particularly if paired with an inability to take breaks. The obvious example here is titles like FromSoftware’s Elden Ring, games that do not offer an ability to pause gameplay if exhaustion or fatigue set in, but this also impacts genres such as VR and motion controlled games, where exhaustion may set in more quickly, and necessitate more taking of breaks.

Games with major online multiplayer components are also impacted, by the fact they are often designed not to support pausing during gameplay. Games with lengthy unpausable cutscenes, or puzzles based around acting quickly on a time limit without losing focus on your inputs, can also become more challenging when gaming with chronic fatigue.

Shortness of Breath may seem like a similar symptom, but I have specifically discussed it separately because its impacts are more obviously felt with physical exertion over mental exertion. Games that are built around persistent motion controls, with no non-motion alternative, are particularly difficult to play with shortness of breath. For what it’s worth, I am really glad that Skyward Sword HD contains a non-motion control alternative control scheme, because in cases like this it can be really useful to offer players.

Muscle aches, pain, and weakness are symptoms of Long Covid that all have very direct parallels with other disabilities, in how they impact gameplay and the support options they need to comfortably game. Options such as turning button mashing sequences to button holds or single presses, reducing input complexity, reducing rumble, and turning down things like resistive trigger intensity, alongside options to reduce motion control prevalence, all act as ways to support players with muscle pain and muscle weakness, no matter the root cause.

In terms of memory conditions, such as the occurrence of “brain fog”, players are often best supported by tools designed for players with cognitive disabilities, such as the ability to re-read previous dialogue in a pause menu, reminders for quest objectives, mini maps with waypoint pathfinding, and other tools designed to help players with conditions such as ADHD.

For players with Long Covid who are struggling with persistent dizziness, accessibility tools designed for players with motion sickness are often useful, such as offering wider Field Of View options in first person games, a persistent centre screen dot, third person perspectives where possible, and ways to alter things like motion blur.

For players with newly onset Tinnitus, existing settings to remove tinnitus sounds from games can be useful, and for players with ear pain, settings designed to normalise game volume to a set consistent level can help avoid spikes in noise that trigger pain.

I’ve talked at length in the past here on Access-Ability about the fact that anyone, at any time, can become disabled without much warning. From physical accidents occurring causing fast onset disability, to the slow process of ageing impacting vision, hearing and movement ability, being non-disabled is often a temporary state of being, and one that is open to change.

We are living in a world that has decided that a certain percentage of the population catching Covid-19 isn’t a big deal, and that so long as it doesn’t kill you instantly, contracting the virus isn’t such a big problem. But for many people it is still a disease that risks death if they contract it, and for those lucky enough to survive, it still has a good chance of becoming a long term disability that you have to learn to live with, a disability that will impact your ability to do many daily activities, including playing video games.

In an ideal world, I wouldn’t have to frame accessibility in video games discussions in terms of self interest, but I know that, for some of you watching, feeling like this topic might someday impact you personally is the only way you’re likely to start caring about accessibility support for disabled gamers today.

If you can’t care about accessibility support for people who are currently disabled, care about it out of self interest. It’s really not that far-fetched to imagine that you might in the coming years find yourself living with symptoms of Long Covid, and suddenly a lot of the accessibility support tools that we talk about on this show might be things that you actively require to keep gaming, rather than hypotheticals that only other people have to deal with.

Long Covid is a disability, and increasing numbers of people are going to have to come to terms with the fact they could become disabled pretty easily, and suddenly they need many of the kinds of accessibility support tools that this show advocates for.