On the morning that Broadway shut down in March 2020, Joel Fram woke up feeling like a steamroller had rolled over him on its way somewhere else. He had a high fever, which evolved into a terrible sore throat and trouble breathing. Like countless other New Yorkers, Mr. Fram, the conductor of the Broadway show Company, had gotten Covid-19 in the city’s crushing first wave.
Two years later, he is still recovering.
His initial symptoms faded after a few weeks but then returned in the familiar constellation we now know as long Covid. Fatigue so deep that he would fall asleep during a conversation. Shortness of breath. A constant, painful migraine behind his eye.
“It felt like I was in a box all by myself,” he said. “The world was in monochrome, when for everyone else, even though we were in the middle of a pandemic, it seemed to be in Technicolor.”
As cases of Covid plunge in New York and around the country, and states lift mask mandates, people are eager for any news that the pandemic may soon be over. But for those with long Covid — it afflicts as many as 30 percent of those who caught the coronavirus — the fight often goes on. The world of long Covid is sort of like a battlefield after the battle has ended. Sufferers survive, but they have lasting injuries — sometimes invisible to others — that they must adapt to or fix.
Mr. Fram, even at 54, was used to having boundless energy. He could go to lunch, conduct a high-energy show like “Wicked,” do a Zoom call with his mother, bake a cake, wake up the next morning and do it again, a friend said. As the son of a urologist and brother of a cardiologist, he was also used to doctors having answers to his problems.
Suddenly, he couldn’t do a fraction of the things he would normally do. At home during the long Broadway shutdown, his anxiety grew. He swung between panicked and depressed.
“There was a period of time where all I could think about was long Covid,” he said during one of many interviews over the past few months about how he finally become well enough to return for his Broadway show’s reopening last November. His story illustrates how determined — and fortunate — sufferers have to be to find the right care.
“Would it be chronic?” he wondered. “Would I have to give up my conducting career?” He started obsessing over the unfairness of it all. “If I wasn’t thinking of that, I was just thinking about how lucky other people are and how I wasn’t included in that category.”
An Early Love of Theater
Mr. Fram discovered his love for theater at an early age. He grew up in Houston, the middle child of parents who had met at a musical (“Stop the World — I Want to Get Off”) and who liked to take the family to see shows when they came to town. Mr. Fram pored over Broadway albums in his mother’s record collection, and in high school he was directing musicals himself.
By the time he was a freshman at Yale studying music, he had decided he wanted to be a conductor. As a young musician in New York, he began working his way up through the musical theater world. Over the years, he has led the music for “Cats” and “Wicked,” among other productions. He and his husband, Martin Lowe, a fellow music director, live part time in New York and London as the work takes them.
In 2016, the theater director Marianne Elliott approached Mr. Fram with an idea. She wanted to update “Company,” Stephen Sondheim’s classic musical from the 1970s, by flipping the gender of the main character, who contemplates settling down as he turns 35, from male to female to make the show more contemporary. Mr. Fram agreed to collaborate and oversee the music.
That August, they met Mr. Sondheim, then 86, to ask for his permission.
“We were completely terrified, and we wanted him to say yes, so badly,” Mr. Fram said. “And to his credit, he basically said, ‘Do a workshop, capture it on video and send it to me and I’ll see what I think.’”
When Mr. Sondheim gave his approval, Mr. Fram, the show’s musical supervisor, rearranged vocals and gathered musical talent for the show. It first opened on London’s West End in 2018 and was slated to open on Broadway on March 22, 2020 — Mr. Sondheim’s 90th birthday. Broadway shut down on March 12.
The tight-knit Broadway world was hit hard by Covid. Danny Burstein, then starring in “Moulin Rouge,” was hospitalized; Nick Cordero, a 41-year-old Broadway actor then in Los Angeles, died. Mr. Fram was not hospitalized, and by early April, he thought he had recovered. But a few weeks later, things changed. “It was like someone turned off the switch on my metabolism,” he said.
In the middle of a yoga workout, he put his head down and thought he would faint. As the days passed, he developed joint pain, profound fatigue and breathlessness, feeling winded after walking just three blocks.
He went to a cardiologist and, to his shock, passed a stress test. Unsure of how to get well, his anxiety ballooned. In the summer of 2020, he took the next available appointment at Mount Sinai’s Center for Post-Covid Care, one of the first long-Covid clinics in the nation. It was six months away, in January 2021.
Looking for Answers
People seeking care for long Covid typically are sent to an array of specialists depending on their symptoms, primarily to check for organ damage from their infections. But many long-Covid patients, doctors say, test within normal limits on these conventional measures.
Mr. Fram was in that category. When January arrived, an intake physician sent him to a round of specialists: a rheumatologist for his swollen joints, a pulmonologist for his shortness of breath, a cardiologist for his chest tightness. Everything tested with normal range.
“On one hand, that’s great news,” said Mr. Fram. “On the other, it is a kind of doorway to existential despair, because it’s like, what is wrong with me then?”
An enormous research effort is underway to determine exactly what long Covid is and how to treat it. The main hypotheses are that it is related to persistence of the virus in parts of the body, and to continuing inflammation related to the body’s immune response to the virus. Until there are clearer answers, treatment at post-Covid clinics for broad symptoms like fatigue and brain fog varies widely. Some patients are offered physical therapy. Others get reassurance and practical tips: Stay well hydrated; do daily, low-level exercise.
Dr. Rany Condos, a pulmonologist and the director of the Post-Covid Care Program at New York University, said about one-third of the patients at her clinic test normally on conventional measures despite debilitating fatigue or breathlessness. She said one of her most important roles is to make these patients feel heard, even though science does not yet have all the answers to what is wrong with them.
“Over the course of months, most patients slowly do improve,” she said. “Whether we have anything to do with this is not clear. In many of these cases we are not really intervening.”
Mr. Fram knew the heavy demands of the job he was desperate to return to. To succeed, he would need enough energy to conduct one or two shows a day, not to mention make it through several very long rehearsal days before the show’s opening. He needed to feel he was doing his all to get ready.
At the Mount Sinai clinic, doctors took an assertive approach, telling Mr. Fram that his long-Covid symptoms, like many people’s, appeared to be a form of dysautonomia, a blanket term for a syndrome in which a person’s autonomic nervous system — which controls heart rate, breathing and other processes —does not function normally.
As treatment, a cardiologist prescribed an intensive aerobic program, known as the Levine Protocol, that is often used to treat another kind of dysautonomia, POTS — postural orthostatic tachycardia syndrome — a disorder in which sufferers can get lightheaded just standing up. She also gave him a beta blocker because of irregular heartbeats she noticed on a scan.
Mr. Fram started walking 30 minutes a day, then 40, up to 70. Eventually he hired a personal trainer and started doing situps and planks. But although he was getting through the exercise, he found that over all, his fatigue, headache and depression were getting worse.
His fatigue, which he put at about a 7 on a scale of 1 to 10 before, skyrocketed to a 13. “I was getting more and more upset, anxious and depressed,” he said. Late last March, he had dinner with a friend who happened to be married to a doctor at Mount Sinai. They asked him how it was going, and he burst into tears.
“What does Dr. Putrino say?” the doctor, Brian Kopell, asked him. He was referring to Dr. David Putrino, who had been heading up long-Covid rehabilitation for Mount Sinai. “I don’t even know who he is,” Mr. Fram replied.
Rethinking Rehab
Later that night, Mr. Fram dashed off an email to Dr. Putrino, explaining his frustration. To his surprise, Dr. Putrino wrote back the next morning.
“It does sound like you’re doing all the ‘right’ things here to no good effect, so let’s see if we can really dig in and identify how to get you on track for recovery,” he wrote.
Mr. Fram soon learned that Dr. Putrino and his team — who were working for a separate center treating long Covid at Mount Sinai — do not recommend long-Covid patients jumping into aerobic rehabilitation, as it tends to be too taxing and aggravate symptoms. A growing body of research is behind him; but even within the same hospital system, not everyone knew.
“We are not pushing people like we would with pulmonary rehab or cardiac rehab,” Dr. Putrino, the director of Mount Sinai’s Abilities Research Center, said in an interview. “Pushing people will categorically make them worse.” Instead, his goal is to retrain the autonomous nervous system very gradually to respond as it did before Covid threw it off balance.
Early last April, Mr. Fram had his first meeting with Jenna Tosto, a physical therapist who works with Dr. Putrino. She gave him what was initially disappointing news. They would have to start over again.
His first workouts were on his back, just doing leg lifts while wearing a heart monitor. He began to see that his heart was not responding normally to exertion. Just lying on the exam table, his heart rate was 115, while a normal pulse might be 60 to 100. Even low-level exercise was causing his heart rate to spike.
Mr. Fram used Stasis breathing as a way to retrain his nervous system to calm down during rest breaks. The basic technique was simple: Breathe in to the count of four, out to the count of six.
As the weeks went by, he started walking for three minutes, resting and breathing for two minutes, then walking three minutes more. In July, “Company” set the return date for its first preview performance in November. The news sent Mr. Fram, who was not nearly ready, into a panic so deep that some days he couldn’t get out of bed.
It was his lowest point, his sister, Dr. Ricki Fram, recalled. But she recommended changes that helped get him back on course. He got off his beta blocker, which had worsened his fatigue. He started seeing a psychiatrist and taking medication for depression and anxiety. He found a therapist to talk with. Slowly, his symptoms began to lift.
By September, he finally was allowed to go to the gym, but only to use the recumbent stationary bike, with two-minute breaks between brief periods of exertion. On the four days a week he wasn’t in the gym, Ms. Tosto began to weave conducting practice into his regimen: Conduct for 15 minutes, then breathe for 10. Conduct for 20 minutes, then breathe for five.
With the support of his new team, Mr. Fram made it back to rehearsals last October, even getting through two grueling 14-hour days. The day of the first preview before a live audience, Nov. 15, dawned bright and cold.
“Let’s do a symptom check,” Ms. Tosto said via Zoom during his workout at the New York Sports Club that morning, smiling from a phone resting on the bike’s monitor.
Mr. Fram described his fatigue after the long days, his anticipation about this night, which he had focused on for 18 months. Ms. Tosto told him to keep his workout exertion level to a 4 out of 10, to reserve more energy for the performance.
“I couldn’t be happier for you,” she said. “You got this.”
The Return
As the audience gathered outside the Jacobs Theater that night, their proof of vaccination in hand, Mr. Fram took 20 minutes to lie on the floor in his dressing room, doing his Stasis breathing and listening to Aaron Copland’s “Appalachian Spring.”
In the theater, the mood was buoyant. Every seat was full, and there were party hats for each audience member. Just after 8 p.m., Stephen Sondheim himself arrived, wearing a white face mask. He stood at his seat — E1 — and waved to the audience and cast, who had gathered onstage to greet him. Patti LuPone, in the role of Joanne, dedicated the performance to him. The crowd roared. He would die just 11 days later.
Mr. Fram stood at the helm of the 14-piece orchestra, perched on a platform above the stage, backlit but visible. As the music began, he kept time with his whole body. As the notes soared, he raised himself to his toes, his arms expanding into a wide plane.
He felt radiant, ecstatic, not thinking about his long-haul Covid for almost the first time in months. After the show ended, Mr. Sondheim came backstage and told the company to remember that night and hold it close, because they would not have another such night again.
“As a conductor, my vocabulary in a sense is my body, and so every bit of music is expressed not just in my hands, not just in my arms, but my total body,” Mr. Fram said the next day.
“And in a funny way,” he went on, “this whole long-haul process has been about my entire body. In the darkest of times, that was a very negative, very depressing thought. And last night,” he said, “I finally saw my body in a positive light.”
Mr. Fram still has good and bad stretches, which is common; progress in long Covid is seldom linear. Late last month, he had another setback, becoming exhausted for days after he and Ms. Tosto increased the number of minutes he was exercising without a break to 13. They dialed it down again.
Living with long Covid, Mr. Fram said, “still feels a little bit like driving someone else’s car.” Moving his body does not feel the same as it did, and he is not sure it ever will again. But he is back to conducting his show on a full schedule. He is still able, with joy, to do what he needs to do.
“Because of my determination, and because of the hope and the structure that all of these people have given me, I may be driving someone else’s car, but I still can get us around the course in a way that I am proud of,” he said this month. “I can inspire people to really bring their best selves to the performance we are in, because I expect the absolute best out of myself. And I think that is still who I am and that I still do that, every night.”
