Michael L. Barnett is an assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health and a primary care physician at Brigham and Women’s Hospital.
Our office, like those of most primary care doctors, is usually packed. I run around, trying to fit 30 minutes of conversation into 20-minute appointments so I can see 12 patients in four hours while juggling paperwork and phone calls. But last week was different. As waves of covid-19 patients flooded hospitals one mile south, my office went quiet. I had formal appointments with just two patients.
My experience is not unique. Doctors’ offices across the country have emptied. Many practices, including mine, have canceled practically every routine appointment and elective surgery that can possibly wait to avoid exposing patients to covid-19. Millions of Americans have lost jobs, and with them, health insurance and a stable income to pay out-of-pocket health-care costs. Patients who are older and those with chronic illnesses are justifiably afraid to venture into health-care settings and risk contracting covid-19.
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I also sense that some patients might believe that any medical issue that does not threaten life or limb is a distraction from the fight against the novel coronavirus. Practically every online message my patients have sent since mid-March begins with a disclaimer: “I’m so sorry to bother you, I know you must be so busy, but . . . ”
Primary care physicians worry about covid-19. But we’re also concerned about all the other ways Americans’ health may deteriorate during the fight against the pandemic. The intensive care units in which doctors make desperate efforts to save covid-19 patients may be the stuff of your nightmares. But what keeps me awake at night are the calm hallways and empty doctors’ schedules outside emergency rooms and ICU wards.
A second, hidden pandemic will follow covid-19. The question isn’t so much whether it will happen, but how bad it will be. Many diets will slump. Expecting the typical American to keep up with regular exercise under the circumstances is probably a joke. Patients will avoid filling their prescriptions, out of fear of pharmacies or financial desperation. And mental-health issues will flare as the economy worsens and people are stuck at home for weeks.
Unnerving anecdotal reports suggest that the problem could go even deeper. Cardiologists have observed that hospital volumes for the most severe type of heart attack, known as a STEMI, are mysteriously low. Neurologists are also reporting fewer strokes. While it is possible that social distancing is somehow lowering the risk of acute problems such as stroke and heart attack, I fear this is a sign that people are avoiding hospitals — even in extreme circumstances.
Loss of health-care access is a well-known cause of further death and illness after natural disasters. My colleagues at the Harvard T.H. Chan School of Public Health found that, after Hurricane Maria hit Puerto Rico, the leading cause of death was interrupted access to health care. My research revealed that after Hurricane Sandy shut down the Veterans Affairs hospital in Manhattan for six months, veterans had worse blood-pressure control for at least two years after reopening, compared to veterans in Connecticut whose access was uninterrupted.
Covid-19 does not carry the physical destruction of a hurricane. But the reduction in access to health care could rival the aftermath of a large hurricane, and it wouldn’t just hit one stretch of coast or one island.
While we may not be ready to reopen the country, there are things we can do to make it easier for Americans to get some of the health care they need during this crisis.
Expanding Medicaid is essential to cover the preexisting and newly uninsured so they can get not only free covid-19 testing but also adequate coverage for routine health issues. Further economic stimulus packages have to support health-care practices that are seeing their revenue crater because of postponed elective surgeries and decreased office visits. It may seem counterintuitive during a pandemic, but we have already seen reports of significant layoffs of health-care workers and projections of substantial office closures. Once society starts getting back to normal, we will need doctors’ offices for people to visit and the staff to attend to them more than ever.
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Most important, we have to take the hidden costs of deferred care seriously while we manage the worst of covid-19. Health systems won’t get a reprieve when the pandemic ebbs: instead, they should plan now for the wave of new health issues that will either emerge or worsen during the lockdown.
You can also make a difference. If you have a medical concern, reach out to your doctors. They are not too busy to help you. Though we may not be battling covid-19 in the intensive care unit, primary care doctors are supporting the front-line medical troops by keeping everything else out of the emergency room. You can help everyone by taking care of yourself before it’s too late.
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