Irv Lichtenwald

After COVID-19, Many Challenges Will Remain

At the current rate of vaccination, 70 percent of the American population will be fully vaccinated by mid-October, which public health experts believe will put us close to achieving herd immunity.

Assuming vaccinations continue apace and that the vaccines are effective against emerging COVID-19 variants, it seems wise to survey the landscape as we try to determine what comes next. Many who emerge from the pandemic largely unscathed will assume a justifiably celebratory perspective, finally feeling unencumbered for the first time in over a year.

But that won’t be all of us. Maybe it won’t even be most, depending on where people live and what’s happening there, virus-wise. Michigan, for example, is once again surging, this time with the B.1.1.7 U.K variant. While the Texas Rangers welcomed almost 40,000 fans on opening day, the Detroit Tigers limited attendance to 8,000, which looked like far fewer in the stands.

As we transition from managing the actual pandemic outbreak to living with COVID long term, it’s worth taking a look at which aspects of society have been most altered over the past 13 months and what life with the virus looks like longer term. What concerns should rise to the fore as the country transitions to a new normal?

Challenges to American Healthcare After COVID-19

Long COVID – For many of those afflicted with COVID-19, the physical challenges associated with the virus don’t all go away after it’s gone. For weeks and maybe months, these people wrestle with fatigue, brain fog, shortness of breath, headache, insomnia, gastrointestinal challenges, heart problems, and other difficulties they didn’t have before contracting the virus.

Some studies show that from 50 to 80 percent of COVID-19 patients have symptoms—many of which differ from person to person, interestingly—many weeks after supposed recovery. Even for many who no longer carry antibodies in their blood, the nagging symptoms persist.

“This post-COVID syndrome may sound suspiciously like what we see in our patients with autoimmune disorders such as Hashimoto’s thyroiditis or multiple sclerosis or lupus,” says Holly Hendin, PhD, MD. “This autoimmune-like presentation is what I have been seeing in my established patient population, and what I hypothesize will come to characterize many of our new patient evaluations in the coming months and years.”

The symptom diversity, Adam Gaffney, MD, says, is perhaps attributable to both individual illness and collective pain.

“The sad truth is that we are living through a time of incredible trauma, sorrow, and hardship,” Gaffney writes. “This has been a period of prolonged social isolation with no obvious parallel in history. We should expect a surge in both mental anguish and physical suffering that, while connected to the once-in-a-century pandemic, will not always be directly connected to SARS-COV-2 itself.”

If just half of the total number of cases reported were to continue as long Covid, that’s currently about 15 million people in the United States requiring help with some kind of chronic health issue. Since we have every reason to believe there are far more cases out there than those reported, it’s not unreasonable to prepare for 20 million people with a drawn-out illness.

The healthcare system is not really prepared for that, but we need to look into how it might be. As Anthony Komaroff, MD, says in acknowledging that the U.S. didn’t control the virus well, “Bad mistakes rarely lead to only temporary damage.”

Psychological Fallout – There is a sizeable group of individuals with enduring pandemic-related trauma. A year later, maybe that group includes most of us in some way, shape, or form.

Defining the size of the group is only useful inasmuch as it helps the healthcare industry prepare for a potential increase in patient populations. This promises to be a complicated task. There are those who recovered from full-blown COVID but have lingering issues, some of them trauma related. Others tested positive and remained largely well but still may have persistent problems. Still others never tested positive but still display some of the symptoms mentioned previously.

And then there are the people who never had COVID or any symptoms, but who lost family members to the virus, spent months without work, have been isolated for weeks at a time.

“Very much so,” said Dr. Anthony Fauci when asked if he is concerned about a mental health pandemic related to COVID. “That’s the reason why I want to get the virological aspect of this pandemic behind us as quickly as we possibly can because the long-term ravages of this are so multifaceted.”

Unloading the mental health fallout from COVID-19 on a behavioral health system that was taxed, to be generous, before the pandemic seems precarious at best, and potentially disastrous at worst.

According to the Commonwealth Fund, “The 1918 flu pandemic led to reduced educational attainment, higher rates of physical disability, and lower income for individuals who were in utero during the pandemic, suggesting there may even be intergenerational effects.”

While a lot of the funding for post-pandemic mitigation will come from the federal government, the management will largely be left to the states. How well states manage the impact of COVID may depend on how well developed the state system was before the pandemic started.

Vaccines – As of Easter Sunday, more than 61 million Americans—roughly 19 percent of the total population and 23 percent of all adults—were fully vaccinated. On the most effective recent day, more than 4 million doses were given nationwide. The rate of vaccinations has many people looking forward to a summer that is much less restrictive than the last one.

And still, in much of the Midwest, cases and hospitalizations are rising. COVID variants are spreading. The pull to abandon masks and distancing under the assumption that vaccines have nullified the thread is effectively spreading virus variants before enough people can get vaccinated.

“We don’t have evolution on our side,” Professor Devi Sridhar of the University of Edinburgh told the New York Times. “This pathogen seems to always be changing in a way that makes it harder for us to suppress.”

The lesson variants must eventually teach us is that COVID-19 will probably always be managed with new vaccines, much like influenza. Perhaps at some future point COVID may become no more deadly than the flu, but variants can also spread more easily and become more deadly, as is the case with B.1.1.7, which battered Britain for a time and is now rising in the U.S.

“My guess is, enough people will get it and enough people will get the vaccine to reduce person-to-person transmission,” said Paul Duprex of the University of Pittsburgh’s Center for Vaccine Research. “There will be pockets of people who won’t take [the vaccines], there will be localized outbreaks, but it will become one of the ‘regular’ coronaviruses.”

But it will be followed, inevitably, by a different virus that can hopefully be managed rapidly thanks to the technology employed to mitigate the impact of COVID-19.

Science – Oh, wow, but this is the truly vexing challenge staring us in the face when COVID-19 is managed. Incorporating politics, belief systems, and education levels, America’s scientific divide, i.e., what people believe is actually supported by science and whether or not scientists are politically motivated, is at its base of crisis of mistrust and misinformation.

With so many perspectives and so many sources of information, Americans are free to find the news source that supports what they already want to think. The digital age has opened a Pandora’s box of confirmation bias and motivated reasoning, which millions now apply to science they don’t like.

Is there a way out of this situation? Not a straightforward one. Also, to be clear, the political and social dysfunction that seem to paralyze the country are a threat to the world-class scientific institutions the nation took so many decades to painstakingly build.

“If we are not careful, our political dysfunction could endanger our scientific and technological expertise,” writes Darrell West, a senior fellow at the Brookings Institution. “Unless we make meaningful changes that improve political representation and institutional performance, we risk a future where both our politics and science are terrible. That would be a catastrophic outcome for the United States and endanger our economy, society, and global leadership.”

The COVID-19 pandemic illustrates well the clash between personal liberty and public health. If the resolution of that clash happens at all, it will play out over many years and many more public crises. One can hope that we learn to at least discuss these issues rationally and with much less personal vitriol. 

Healthcare IT – A compelling argument for the move to digital health records and complete digital healthcare platforms was the supposed ease of data access enabled by such systems. The promise has proven more alluring than the reality.

“I’m stunned at EHR vendors’ inability to consistently pull data from their systems,” said Health Catalyst CTO Dale Sanders near the start of the pandemic in 2020. “It’s absolutely hampering our ability to understand and react to COVID.”

Perhaps predictably, this inability exists between disparate systems where vendors have focused more on the billing aspects of healthcare IT platforms than the accessibility of data. But kludgy architectures are also a concern within individual healthcare IT platforms.

This has to change. Electronic health record (EHR) platforms that improve billing and revenue are great for individual organizations, but they do little for public health, especially in times of crisis. The COVID-19 pandemic has revealed that the maturation of healthcare IT platforms to date is insufficient and unacceptable. If we suspected this before COVID, we now have no doubt.

In people, in cultures, in organizations, in societies, assumptions about readiness and cohesiveness have little value until they are tested and proven resilient. While faith in American resilience has not been wholly undermined by COVID-19, the virus has shined a bright light on the least stable aspects of our current culture and institutions. Moving forward, the challenge is to overcome the cultural and information schisms before they weaken the institutions that serve as the national foundation.

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