Coronavirus Consequences

Before the pandemic was declared (back when the world was predictable) I’d taken time off from work to go to Washington DC with my son, a college senior.  We planned to visit  an FBI agent who was also a dear high school friend.  She’d kindly arranged for my son to meet with her colleagues to share their job experiences. Emerging from the long North Country winter, I looked forward to the warmer weather I knew we’d enjoy just a few hours south of us.  Mostly I was happy to spend a rare long weekend with my son. Like many thwarted plans, though, my trip was cancelled.

When I finally conceded that DC wouldn’t happen I informed my job I’d be available to work those days. But, despite the chaos of urban areas hard-hit by coronavirus, business is actually slow in many rural primary care offices. Few patients show up for in-person visits.  There are no work physicals to be done (people aren’t working), no sports physicals (sports are cancelled), no pre-operative clearances (elective surgeries have been rescheduled). People are (rightfully) not coming in for routine diabetic or hypertension checks. They aren’t getting bloodwork or mammograms either. 

In short, my services were not needed in my office (which, I know, seems incredible as doctors collapse from exhaustion enduring grueling shifts just a few hours away).  Although the pace has slowed for many offices, doctors are still quite busy trying to stay on top of ever-changing guidelines, remotely attending frequent meetings, and worrying (like the rest of the world) as they struggle to find ways to ease their patients’ suffering.  While necessary, these tasks are generally not revenue-producing.

Borrowed from The Annals of Internal Medicine, 4/16/20

So, I found myself with an unplanned long weekend at home doing not much of anything except deliberately avoiding the news (I highly recommend this).  It was a lovely respite (and only just mildly guilt-producing). Also, I knew I was fortunate and that my job would be waiting for me Monday.

Although America is facing an unprecedented public health crisis, healthcare workers are actually being furloughed from their jobs.  Many of those lucky enough to still be working have taken pay cuts in an effort to offset huge economic losses – a sacrifice most willingly make to ensure the continued care of their patients and the survival of their hospitals. Although ERs and ICUs overflow with COVID patients in heavily populated areas, nationwide hospital volumes are down.

Many people who actually need an urgent evaluation are afraid to seek care. Even I am hesitant to recommend urgent care or ER visits when I’m on call. Doctors are doing a lot of phone triaging and empiric treatment (with pleas to patients to reach back out if they aren’t improving with the telephone assessment and treatment).  The result is predictable.  Rural hospitals, highly dependent financially on outpatient services, are in danger of closing.  Money funneled by Congress in a desperate effort to repair gaping holes in the tattered safety net may not be enough to save them.

But hospitals aren’t the only health care entity in danger. Despite the well known fact that the United States has long suffered from a primary care shortage, physician practices are actually closing.  The American Academy of Family Physicians (AAFP) wrote to a letter to the House and Senate this month requesting “dramatic interventions” to prevent further closures and “bold steps to repair the damage“ already done. In the letter the AAFP stated that “the current fee-for-service structure puts the primary care delivery system one pandemic away from complete collapse.”  Their assessment of our system’s fragility and the impact on patients was bleak:  as primary health care goes, so will the health of Americans.

To add insult to injury, as more Americans lose their jobs they also lose employee-based insurance benefits. I’m hopeful that the current crisis will force Americans to reconsider their opposition to universal health care.  In an article written for Vox this past week, Dylan Scott wrote passionately about the “fundamental immorality” of the US healthcare system. “The flaws in America’s health system have been evident for decades to anyone who cared to look, but the coronavirus pandemic has left no room for doubt:  People will die because the US refuses to treat health care as a public good and a universal right.  They already are.” 

People will die.

In anticipation of returning to work this past week, I decided to catch up on what I’d missed during my blissful news-free staycation at home.  I sat down at my computer last Sunday night and scrolled through the news. The headlines were shocking:  the president threatened to defund the World Health Organization (in the middle of a pandemic!) and Americans were protesting stay-at-home orders.

It seemed unreal – the government wanted to take away funds from the one global organization dedicated to assist in worldwide health emergencies?  How could this be?  A public health crisis of this magnitude requires a coordinated international response.  According to their website, WHO “works worldwide to promote health, keep the world safe, and serve the vulnerable.” Their purpose is to:

• • prevent emergencies and support development of tools necessary during outbreaks
  • detect and respond to acute health emergencies
  • support delivery of essential health services in fragile settings.

These seem like pretty necessary tasks during a pandemic.

I also read about protests.  As the virus continued to spread many states tightened or prolonged their restrictions. Some Americans balked at what they felt was an infringement on their rights. In a not-so-funny tweet, Comedian Patton Oswalt wrote, “Anne Frank spent 2 years hiding in an attic and we’ve been home for just over a month with Netflix, food delivery & video games and there are people risking viral death by storming state capital buildings & screaming, ‘Open Fuddruckers!’” 

It’s clear that many Americans faithfully practice social isolation and that doing so is particularly challenging for people who live paycheck to paycheck.  Staying home may not be a viable option when it impacts ability to feed a family or pay rent. Although some small businesses have become creative in their offerings, it’s also clear that many will be forced to close.  Living in a small community, it’s heartbreaking to learn of friends and neighbors losing their livelihood.  While financial struggles are an understandable reason to want to open up sooner, conspiracy theories, boredom and “un-American” arguments are not.

Still, despite the protests, apparently many Americans are willing to prolong their efforts at social distancing.

Meanwhile, we see frightened (and angry) health care workers plead on social media for people to stay home as they tearfully describe mentally exhausting shifts fighting an unseen villain in gear that is challenging to wear for a few minutes, much less hours on end – obstructing face shields and hard-to-breath-in “disposable” masks that are re-worn.  How long can this go on?

The answer seems to depend on our willingness to make sacrifices now. 

In a New York Times article by Donald McNeil Jr published earlier this week, former president of the National Academy of Medicine Dr Harvey Fineberg makes grim projections. “We face a doleful future.  Exactly how the pandemic will end depends in part on medical advances still to come. It will also depend on how individual Americans behave in the interim. If we scrupulously protect ourselves and our loved ones, more of us will live. If we underestimate the virus, it will find us.” 

It will find us.

The article points out that COVID is currently the leading cause of death in America (surpassing heart disease and cancer) with more than 1,800 American deaths a day since April 7. Future projections by various experts predict deaths ranging from 1.7 to 2.2 million by the fall if we are unable to stop the spread (we are swiftly approaching a million now).  For perspective, the article cites that 420,000 Americans died in World War II.  Obviously the true death rate will depend both on how overwhelmed hospitals are and the percentage of the population that is actually tested (since without adequate testing we can’t know how deadly a virus truly is).

Most experts agree that until there is a vaccine to prevent further spread (or advanced treatment options for those already infected) it simply isn’t safe for people to stop isolating.  The tighter the isolation now, the fewer deaths and the longer the periods between lockdowns. Harvard Public School of Health predicts that without increased critical care capacity or the development of a vaccine intermittent such distancing may be required into 2022 along with intensive surveillance through 2024.  They cautioned that if social distancing restrictions are lifted the virus will quickly resurge. 

In an article in Time this week, the Japanese island of Hokkaido painted a distressing picture of what will happen if restrictions are lifted too soon.  After calling off isolation a second wave of infections were even higher than the first, forcing the island back into lockdown. I’ve also read that China didn’t reopen cities until intensive testing found zero new cases for 14 straight days.  Due to a lack of test kits, the United States isn’t performing surveillance anywhere close to this intensity.  Still, daily reports clearly indicate that we are not there now.

And yet this week (possibly in response to protests as elections loom in the near future) some states started loosening their restrictions.  Preliminary data from these states suggests that this isn’t a good idea.

Chart posted on Andy Slavitt’s twitter account, 4/22/20

So, during a deadly pandemic healthcare workers are being laid off, America is de-funding an organization created to handle such a global health crisis, citizens are protesting the requirement to stay home and some states are conceding to these demands.  All of these actions not only risk lives through direct spread and overwhelming our health care system but they also potentially increase the overall time we will need to spend in isolation.

What can we do?

We should channel our outrage toward making positive changes. The vulnerability of our healthcare system is absurdly evident. In the AAFP letter to government leaders, Board Chair Dr. John Cullen wrote “This public health crisis has identified significant cracks in our country’s primary care infrastructure. Population health will only be achieved when we identify and remove the barriers that exist.”  The greatest barrier is the lack of access to healthcare.  Health care must be a guaranteed American right (not an employee benefit). This has become painfully obvious as hard-working Americans lose their jobs and find themselves without coverage during a global health crisis.

We also need to fund agencies that advance public health.  Recent cuts to the CDC as well as the proposed defunding of WHO will not save money in the long run.  Instead, these actions will cost lives and make it difficult (if not impossible) to anticipate and react to a future crisis. 

We must protect our frontline healthcare workers.  As hard as it can be, our efforts at physical isolation do save lives.  An article this week in CNN quoted the director of the CDC Robert Redfield explaining that social distancing is “one of the most powerful weapons” against COVID-19, “If we can just maximize that social distancing, we can limit this virus’s ability.” 

The good news is that most Americans (regardless of their political affiliation) are up to this task.

There are other ways to help, too. Support your local businesses in any way you can. Check in on your neighbors. And, if you’ve recovered from COVID by at least 2 weeks, you can donate plasma to help in treatment of coronavirus patients.  Go to the Red Cross website for more information:  www.redcrossblood.org/plasma4covid.

(DO NOT) GATHER on Main Street

Finally,  one last message that may have been lost in coronavirus mania.  People still experience health emergencies during a pandemic.  Chest pain, arm weakness or severe headaches are potentially deadly and need to be treated as such. Fear of contracting coronavirus in a waiting room shouldn’t prevent seeking care when that care is necessary.  If you aren’t sure, call your doctor.  Despite advising patients not to be evaluated in the office if unnecessary (for their own safety), most doctors are still physically in their offices.

Telemedicine is convenient, especially for my elderly patients who have trouble getting rides from busy family members to their appointments.  Telemedicine is often adequate for routine complaints and reviewing tests (and for triage to determine if a patient really needs an in-person evaluation). Telemedicine is likely here to stay, which I believe is a positive result of the pandemic. Of course, telemedicine can never fully replace office visits.  There is still value in human touch, even if it is must be (temporarily) delayed. Or when it takes place through gloves.

 

Coronavirus and Change

Change is swift in a pandemic. Two weeks ago no one routinely wore a mask in my office.  Last week was an entirely differently scene.  Not only did I wear a mask and eye protection (and gloves when actually examining a patient) but the entire office staff did as well. In the nursing home I added a gown to my protective gear and entered through a locked side door entrance to see a patient who’d recently returned from the hospital (and therefore was potentially exposed).

Two weeks ago, during the time of mask-conserving, I developed a slight cough and a faint wheeze one night.  “It’s just a tickle,” I whispered into my husband’s back as he drifted off to sleep.  I was really only trying to convince myself.  I woke up a few hours later with a sore throat. I climbed gingerly out of bed, overly sensitive to the mild aching I felt in my joints.  When I got to work I took my temperature. I had a low grade fever. 

If a patient called me with these symptoms, I’d have advised home isolation, symptomatic treatment and a call back if symptoms worsened. I’d then add them to a growing list on my desk of people to check back on in a few days.  While I might have wanted to order a coronavirus test (to help track the spread and quantify the disease prevalence in my community) I would not have since testing in rural areas is still quite limited. 

But since I’m a doctor who could potentially expose a lot of people, I put on a mask, closed my office door and called the employee health nurse. She advised me to get an order from my primary care doctor for coronavirus testing. “I think it’s just a spring cold,” I told her. 

“You are a presumed case.  You can’t return to work until it is negative,” she insisted. 

Of course, she was right.  I texted my husband to let him know I was getting tested. I texted my son and asked him to bring down the spare mattress from storage. I reassured him that I didn’t feel very sick (I didn’t) and that it was just an over-abundance of caution (I hoped). Mostly it was an opportunity to practice self-quarantining in case of future infection.  Part of me, though, was worried about my family’s health if I was truly infected by coronavirus.

I wiped down my desk and everything I’d touched and drove myself to the testing area. On the winding back road I passed a sign flashing:  IF YOU ENTER VT TO STAY SELF-ISOLATE 14 DAYS. The sign was on the NY border (home to the overwhelming majority of cases) so I shouldn’t have been surprised. After weeks of anticipation watching the world fighting coronavirus on a distant stage, it finally seemed real.

I pulled up at my appointed time to a trailer ominously labeled “Disaster Support.”  I’d been instructed beforehand not to get out of my vehicle so I waited for someone to approach. A friendly staff member in full personal protective equipment (PPE) including mask, face shield, gown and gloves emerged from the trailer like someone from a science fiction movie.  She explained how she would get the specimen and asked me to hold as still as possible.  “When you think I must be done, it will be longer and when you think it’s finally over, it won’t be yet.” I tilted my head back on my car seat as instructed and closed my eyes as she plunged the swab deep into my nose for what seemed an eternity.

Her assistant, also in full PPE, held out a test tube for my specimen. “Wow,” she said. “She didn’t even flinch.” I was tempted to brag about my natural childbirths and dental work without novocaine but the occasion seemed too somber. From experience I was confident I could handle extreme physical pain in short bursts. I wasn’t so sure about my ability to endure mental pain, especially when it will likely be prolonged.

I thanked these brave members of the front line and drove off as two cars pulled in behind me for drive through testing. I wondered how much crazier the world would become over the next few weeks.

At my house I turned off the car and put on gloves and a mask (just in case my sons were in the kitchen). I was surprised to see that my husband had come home early from work and was already cooking homemade chicken noodle soup. While I was truly grateful for his care and concern I worried that he should be saving his time off for when one of us was really sick.

In my kitchen I methodically wiped down every surface I thought I touched before work that morning – sink, coffee maker, door knobs, drawer handles, milk carton, and countertops. I followed the same meticulous procedure in the bathroom. I moved through the house retracing my steps with disinfectant in hand. I gathered everything I thought I might want or need along the way in the event of a prolonged illness. I retreated to my room.

I spent the next day (which was normally my day off) in bed waiting for more worrisome symptoms to develop.  When they didn’t, I decided to work from home doing telemedicine.  I called patients from the safety and comfort of my bedroom, hoping they couldn’t see I was still in my pajamas after noon. When I ventured out of the sanctity of my bedroom I was careful to keep six feet from everyone.  I washed my hands a lot and sanitized them even more. I wiped the surfaces I touched with disinfectant.  Meanwhile, my husband slept poorly on a mattress in the living room. His work had advised him to remain home until my test results were back since he managed a residential facility.

It took two and a half days for my results (my sister informed me by text that if I worked for Chevron I’d have had the results in 15 minutes). I tested negative.

Although waiting for this result was nerve-wracking (not to mention disruptive to my family’s routine), I experienced for myself the advice I’d been giving my patients. I gained an appreciation of how difficult it is to follow isolation and self-quarantine recommendations diligently. I imagined this would be especially true if a person wasn’t actually being tested. It would’ve have been easy to slack on my self-imposed isolation when I felt better if there was no definitive end to it (a negative test).  Even my own family thought I was excessive in my efforts to keep them safe.

I did feel better prepared in the event of a true infection.  Mostly, though I felt lucky to have space in my home to be able to self-quarantine safely, to have a loving husband to make me chicken noodle soup and to have a job willing to let me work from home. I know that many Americans are not as fortunate.  Large families crowed into small apartments are likely to spread infection quickly, not to mention the impossibility of following any quarantine recommendations in homeless populations. People in jails and nursing homes have to depend on the vigilance of their caregivers.

My routine at work these days is much different than what it was even a week ago. For most of the day my office door is shut while I talk on the telephone or video-conference with my patients. For many routine complaints this type of distant care is convenient and adequate. I’m a doctor who believes in the importance of touch, though.  I like to lay a reassuring hand on a frightened patient or to hug a grieving one. Telemedicine does not allow for this type of intimacy.

Things have changed at home too. I take off my clothes at the side door to my bedroom, throw them directly into the washer, and then head right for the shower.  I alternate the shoes and coats I wear to work, leaving them in a separate room for at least 24 hours before I wear them again.  I wipe down my phone, watch, and sunglasses.  I wear a mask in public to protect my community.  I try my best to take care of myself. Still, I cry most days – sometimes just a few silent tears and sometimes uncontrollable sobs. 

I know that grief and fear are widespread.  People struggle with the anxiety and uncertainty of their loss of control.  Many feel imprisoned. Most of my patients stress over finances – younger ones because they are newly unemployed and older ones because they are watching in horror as their retirement savings dwindles. I worry a lot about the mental health crisis that is sure to follow this infectious one.  Even in normal times our country lacks adequate access to mental health care. 

It’s no surprise that studies of people who’ve lived through previous epidemics, like SARS and Ebola, show a high incidence of depression and PTSD during the scare, with numbers approaching nearly 50% in the aftermath. Preliminary studies from China of the COVID pandemic report even higher incidences of psychological affliction. Healthcare worker statistics are the most dismal.

What we need is to find the balance between complacency and panic. There are some benefits to fear. On a national scale, it can help mobilize resources.  On a more personal level, fear keeps us mindful and vigilant of our own safety. Too much fear, however, is debilitating and potentially leads to more serious mental health problems. I heard panic in my mother’s cracked voice as she told me how worried she was about my sister, a hospital nurse. I heard it in my father, too, when he asked me if a “Do Not Resuscitate” order excluded intubation (prompting me to finally open the envelope containing his health care proxy papers that he mailed to me five years ago).

The United States has been criticized as having the worst response to the pandemic of all nations. Experience from previous epidemics show that strong leadership, community kinship, credible information and communication play a pivotal role in lessening anxiety. Leadership and competent decision making are essential. Initial dismissal of the potential threat as well as mixed messages from government and health officials created a distrustful and scared population.

But our country’s early failures don’t have to define our ultimate response.  We don’t need to return to “business as usual” after the crisis abates.  We can use this opportunity to demand social change. As more people file for unemployment (and lose their employee health insurance), the long overdue need for universal healthcare is clear.  As we seen the racial disparities in death among African Americans infected with COVID, we can no longer ignore the inequalities of our society and our healthcare system.  As we look at the suffering of our community members, family and friends we must be compelled to fight for greater access to mental health counseling,

As a traumatized society, we will need to find ways to mourn our great losses together.  We will need to look for hopeful signs and share our optimism and compassion with others. When raw grief loosens its painful grip over time, we will no longer take our blessings for granted. We will share our gratitude and love as we continue to check in on our friends and family.

Finally, we can shift our mindset from social distancing to physical distancing. As Rabbi Yosef Kanefsky beautifully said, “And the very last thing we need right now, is a mindset of mutual distancing.  We actually need to be thinking in the exact opposite way:  Every we hand that we don’t shake must become a phone call that we place.  Every embrace that we avoid must become a verbal expression of warmth and concern.  Every inch and every foot that we physically place between ourselves and another, must become a thought as to how we might be of help to that other, should the need arise.”  We don’t have to wait for the crisis to be over either. 

For credible information (or if you are wondering what you can do to help right now) check out the “While at Home” website. (https://whileathome.org/). Live by the words of Mahatma Gandhi.  Be the change that you wish to see in the world.