The coronavirus has affected humanity globally, from the report of a nine-month-old UK baby secluded at home who has never seen another child, to parents unable to work in order to care for loved ones and grandparents who have not seen families for months-on-end, making their lives even more isolated and lonely. Many know someone who has been infected or passed away as a result of the virus.
Here, we take a look at the medical side of this crisis and how it affects those on the frontlines.
The pandemic has also redefined dangerous professions, as medical staff and essential workers, such as grocery store employees, are added to the military, firefighters, and police in the at-risk category. Overwhelmed physicians and hospitals caring for those infected have contracted the disease in large numbers despite protective measures. In the US alone, 300,000 healthcare workers have been infected, such as New York’s Dr. Fazila Lalani, with 840 reported deaths.
This first global plague of the 21st century has infected more than 500 million people worldwide and resulted in the untimely deaths of over 1.6 million people. Clearly, these numbers are only a fraction of the real toll as many millions have not been tested or their cases reported, while many deaths, especially in the rural areas of developing countries, may not have been diagnosed as COVID-related.
The numbers are staggering and self-evident. Yet, despite the science, there are still those who claim the virus is a hoax and refuse to take appropriate precautions, most notably in the United States. Protective clothing itself has become a reflection of one's political philosophy, with scant regard for its contribution to the spread of the virus.
Science and facts themselves are trumped by ideology, a sad reminder that humanity has really not progressed much since medieval witch-burnings and denial of the planetary orbits. Images of temporary morgues inside refrigerated trucks and pleas by physicians to abide by recommended precautions have had little impact on a segment of the population, who may infect others, causing deaths.
Belgium leads the world in cases and deaths per capita, with the USA, Brazil, India, and Spain close behind, while Southeast Asia, New Zealand, and Africa show the lowest impact. In Kenya, the average age of the population is around 20, which may account for some of the resiliency prevalent there.
Surani
What is the moral responsibility of those who do not take recommended precautions, become ill, and then add to the stress on the healthcare system? What about the responsibility of governments and politicians whose approach has been denial or downplaying the impact? This was the case in the USA, and is still true in places such as Belarus and Brazil, to Tanzania and Turkmenistan. They prefer to minimize the problem by not disclosing and discussing infection rates or having effective measures against the spread of COVID-19, while their citizens suffer the consequences.
Dr. Salim Surani, Director, Pulmonary & Critical Care Fellowship Program, at Bay Area Medical Center in Corpus Christi, Texas, remarks that “This pandemic would be remembered in history as the most politicized tackling of a disease. We are fighting a war against the coronavirus, stupidity, and politics.”
Salim believes that while we can win the war against the virus, mixed messaging from leaders has “cost significant morbidity, mortality, and economic turmoil. Science was ignored and rhetoric was dominating, leading to the cost the world, and especially, the USA is paying.”
The Global Impact
This virus has also affected medical care and its delivery. It has accelerated the development of new healthcare technology adoption into weeks, instead of years. One example is telehealth. While not new, as even our Ismaili professionals are using it for consultations in many countries with AKDN institutions, its use has not been widespread. During this pandemic, however it has become far more common, often replacing the doctor’s visits for minor ailments with a virtual conference. This trend is likely to continue, perhaps allowing more frequent consultations, especially for those who have difficulty traveling to see a doctor.
Global poverty is increasing as many are out of work and businesses have closed or forced to return to their villages. Almost 400 million people in India and two million in Kenya have been driven into poverty. Coupled with resultant stress and anxiety, the mental health of people has been affected significantly, with potential long-term effects, and suicide rates are on the rise.
The Aga Khan University, Karachi, has conducted clinical trials on the Cansino COVID-19 vaccine. Researchers also collaborated with the University of California San Francisco and the Gladstone Institutes in the USA to see if human neural cells can be infected by the virus.
Dr. Tasleem Nimjee
Impact on Physicians and Staff
Dr. Tasleem Nimjee is the physician lead for the Covid Emergency Response at Humber River Hospital in Toronto. Anxiety has been part of her life, as she slept in a different room from her family, worried daily that she might bring the infection home. She also wrote a final letter to her children, to be opened in case she succumbs to the virus.
We can understand why Tasleem was named as TorontoLife magazine’s 50 most influential people in the city. She performed many simulations with staff and helped streamline processes to cope with the influx of patients at its early stages, also performing the first intubation at the hospital. As a member of the Aga Khan Health Board for Ontario, she has taken a sabbatical from her position to focus on the larger community at this time. Service has been part of her upbringing, and she felt she had no choice but to put the community first and do whatever she could to combat the disease and save lives.
At the Province’s highest acuity hospital, she and her team had to revamp treatment processes and protocols to care for the influx of patients, which was made more difficult by the sealed negative pressure rooms in which they were placed, and which made communication with them difficult. Donated baby monitors made this a little easier, but as families were unable to visit, she made it a point to call as many as she could on a daily basis, to let them know the patient’s condition.
“None of our preparation manuals have prepared us to handle the death of our colleagues in our service,” says Salim. He has treated over 1,000 COVID patients and has lost four physician colleagues to this disease and three more admitted to hospital, placing enormous physical, mental, and emotional stress on all involved.
As family members were not allowed to visit patients who were dying alone, his team “became their extended families, holding their hands during their last breaths. This has been the toughest situation I have faced in my 25 years of taking care of ICU patients.”
Dr. Arif Nathoo
Impact on Patient Care
According to Dr. Arif Nathoo, Co-founder, and CEO of Komodo Health in New York, “COVID has massively accelerated the adoption of digital tools and platforms to support patient care.” He says, “We're seeing thousands of new providers adopting telehealth each week. In total, telehealth rates are up six times across the country (and over ten times in certain geographies). More importantly, in a world where patients have to make a trade-off between addressing their own health issues and potentially exposing themselves to COVID, telehealth fills a much-needed gap.”
There's likely to be permanent increases in telehealth for a few reasons, says Arif: “First, insurers are standing behind this, increasing reimbursements and encouraging patients to use virtual services and digital tools.” Insurance companies are seeing the benefit to patients and reduction in their own costs. As another COVID wave is already here, he adds, “this will hardwire the role of telehealth for treating certain conditions. Finally, this is a shift that patients want. If they can avoid a drive to sit in a waiting room for an hour, they will.”
The staffs’ stress levels can be understood when we realize that ICU patients should have a 1:2 nursing care but are now at a 1:6 ratio. This, says Salim, can “decrease the chance of survival and increase complications and delay in care,” a reason for the high mortality rate. “The notion of flattening the curve is based on slowing the disease transmission to prevent the health care system from collapsing, especially in the surge.”
Ethical issues
There are ethical concerns as well that are generally not discussed. Who gets treated first, which other surgeries get postponed, and how does one make these decisions? At Salim’s hospital, a triage committee, not involved in patient care, has to decide these difficult questions based on evaluating “who may benefit from the care most, who may least benefit from care, and who has the least chance of survival with high resource utilization.”
These are, of course, life and death decisions that have to be made as beds and staff are at capacity levels. “Surprisingly,” says Salim, such care-rationing “is happening in USA hospitals today,” and presumably, elsewhere also.
Impact on Hospitals
A Komodo Health report affirms that routine medical tests to detect and monitor cancer and other conditions have cratered in the United States since mid-March, as the coronavirus spread and residents stayed home (unless shopping for food and toilet paper). Diagnostic panels and cancer screenings fell by as much as 68% nationally. These tests and consultations are key income sources for healthcare providers but they had to reduce their use to care for COVID patients.
Arif says, “It's going to change the nature of care provision and the way that patients engage their providers. In the near-term, there will be a lot of hospitals that shutdown and smaller facilities that will have to consolidate due to shrinking elective procedure volume.” He believes there will be a recovery in 2021 but at lower levels, as “Providers will have to adopt a hybrid of virtual and traditional engagement. And patients will continue to see new tools coming to market faster than ever before.”
Most hospitals have coped with the influx of COVID patients, notes Salim, by utilizing step-down units, recovery rooms, Post-Anesthesia Care Units, and extra rooms in the Emergency Department as makeshift ICU areas. He adds that “Hospitals have relied on out-patient surgeries and procedures as a profit center. But with the pandemic, these surgeries have been canceled to accommodate COVID patients.” Overworked staff, capacity level operations, and an increase in infections among healthcare workers and the public are the most pressing issues, according to him, as the world awaits more vaccinations to create herd immunity..
Reported declines in admissions for acute medical illnesses, suggest potential harm to patients deferring care. Zoran Lasic, an interventional cardiologist at Jamaica Hospital Medical Center and Lenox Hill Hospital in New York, noted the decline in New York of patients reporting coronary symptoms, and said, “I think the toll on non-COVID patients will be much greater than COVID deaths.” We may have to wait for another dismal statistic to see if his prediction is accurate.
While the pandemic has drawn attention to those infected, another issue raised is how to care for those with non–COVID-related maladies. The new risks have required a re-evaluation of current standards of care, to protect the ill from the hospital environment, while also protecting caregivers and maintaining critical care capacity for the most serious cases.
The healthcare system has changed radically in the process of addressing the coronavirus and how medical care is delivered. Michael Grossbard, Chief of Hematology at New York University’s Langone Hospital, has said, “Our practice of medicine has changed more in one week than in my previous 28 years combined.”
Impact on Private Practice
The pandemic has affected how outpatient care is delivered. To minimize the risk of transmission of the virus to either patients and medical staff, healthcare providers have opted to defer elective and preventive visits, often resorting to telemedicine appointments. Patients have also been averse to risking exposure by visiting a hospital or doctor’s office, unless essential.
Health care offices are already businesses also being affected with the rest of the economy, with some reporting 70% declines in services offered, and a New York Times report indicates that 8-15% of practices will close. Salaries of clinical staff have been reduced, with staff laid off. Some physicians are also choosing to retire earlier, given the circumstances and the stress of COVID. In Michigan, at the end of March, health care businesses were behind only restaurants and bars in submitting unemployment insurance claims.
Dr. Munaf Shamji
Cardiologist Dr. Munaf Shamji, from Los Angeles, recalls that during the first two months of the pandemic, their practice shut down a satellite office and patient numbers shrunk by 30%. “However,” he says, “since then, we have been blessed that our practice continues to do the same volumes. We have instituted some innovative ways to provide care that includes telehealth and remote monitoring of patients to continue to provide care to our patients.”
Munaf is negotiating with a large managed care organization that will double his practice. “Because of COVID, potentially, we are going to increase our practice size within three months, whereas that would have taken us 18 years to do so in the past.” He believes his team of 24 people can take on a lot more work and provide even better care with less utilization with remote monitoring, telehealth, and using technology to improve communication with patients.
“With COVID,” Munaf says, “the expectations will change and if we are able to provide the same care with less resources, it will be acceptable. As such, using guideline-based protocols implemented in our office workflows, providing high-level sophisticated care, is a real possibility and I think quite exciting.”
Perhaps, once the virus is contained, deferred medical procedures may once again be activated, allowing those with ailments to be cared for appropriately while allowing clinical staff to return to work.
Impact on Research
What is not often in the news and discussed is the long-term impact on medical and pharmaceutical research. The focus has shifted to developing drugs to treat the virus and vaccines to resist it, as these are the most immediate health concerns. They also make the most strategic business sense. But the disruption of clinical trials due to the pandemic is also significant. Delays and postponements of such trials will affect future development and delivery of drugs for other illnesses, in an attempt to refocus energies and to keep patients safe.
As an example, the CEO of Belgian drugmaker Galapagos, announced earlier this year that there would be a pause in patient enrollment in seven studies of Filgotinib, a drug being developed with partner Gilead Sciences to treat diseases of the immune system. Soon after, Eli Lilly said it would delay the start of new clinical trials and stop enrollment in “most” ongoing studies.
The increased collaboration, however, between research and medical organizations to confront this crisis is also unprecedented. If this continues, more drugs and treatments may reach patients quicker in the future, as seen with the record pace at which new vaccines have been developed.
New Learnings
Among new information gleaned from the treatment of this virus is a better understanding of side effects, like blood clotting and kidney failure, and promising new treatments such as convalescent plasma, antiviral drugs, and steroids.
Tasleem’s Humber River Hospital is the most digitally advanced in Canada, and the only one with a Command Center, such as at Johns Hopkins in the US. As the Senior Director for Medical Innovation and Transformation, she was involved in the implementation of this automation, which uses artificial intelligence for patient analytics. It allows identification of patients in critical stages, and any changes in condition, using bedside monitors, allowing the Command Center to alert staff. More widespread use of such processes would offer better outcomes for patients.
Hospitals have now learned to better prepare for the pandemics, as more are possible, and, says Salim, “Post-HIV, wearing gloves has become the universal precaution. Going forward, in the health care setting, wearing the mask may be a new universal precaution.”
On an optimistic note, Munaf believes that the delivery of care will change substantially for the better, and that “The use of technology, telehealth, remote monitoring, use of algorithms, including use of Artificial Intelligence in improving care and efficiency will come to the forefront. What may have taken 10 years is now happening within a year or two.”
This pandemic has shown in stark relief, the ability for a global focus to synthesize and apply knowledge for innovation at a speed not known since the last World War, as vaccines have been the priority. At the same time, there are those who dispute facts and scientific knowledge. This may bode well for cures in other areas, such as malaria, cancer, and combating global warming, which poses another looming existential threat.
With the promise of new vaccines making a difference, perhaps the greatest challenge, then, is that of helping those reluctant to seek care, while suffering from serious health issues. The focus on social distancing, proper hygiene, PPE for health care workers, and the need for increased testing are all important. However, with fewer visits to physicians for potentially life-threatening conditions, the profession and healthcare policy need to find a way to accommodate non-COVID patients also, a Herculean task in the face of new waves of infection and hospitals at capacity limits.
But every life counts, and that is the new moral imperative in our world of complex ethical dimensions.
References:
- New England Journal of Medicine: The Untold Toll — The Pandemic’s Effects on Patients without Covid-19.
- Lancet Journal: “Reporting on suicidal behaviour and COVID-19—need for caution."
- Brookings Institution: “The human cost of the pandemic…”
- Health Affairs: “The Impact Of The COVID-19 Pandemic On Hospital Admissions In The United States.”
- Reuters: Special Report: “As the world approaches 10 million coronavirus cases, doctors see hope in new treatments."
- Stat: “As Covid-19 spreads, disruptions to clinical trial and drug development accelerate."
- JAMA Network: “How Will COVID-19 Affect the Health Care Economy?"
- Brookings Institution: “The impact of COVID-19 and the Policy Response in India.”
