A COVID-19 Hangover

Despite the encouraging decline in US COVID cases—a drop of 75% since mid-April and over 90% from the January 2021 peak)—I’m experiencing what feels like a COVID-19 hangover; I suspect many of you may feel the same way. While unpleasant, hangovers usually resolve quickly and the memory fades over time.

Over the past year, as we revisited the history of the horrible flu pandemic of 1918-1919, I realized that 100 years later its devastating impact had been largely forgotten. Although pandemics do indeed end, do they cause lasting changes?

Could we finally be moving beyond this pandemic? It’s hard to believe that we are truly coming out of the nightmare that was 2020. When the Centers for Disease Control and Prevention (CDC) abruptly reversed its COVID-19 guidelines in May and said that vaccinated Americans rarely needed to wear masks, it created both anxiety and uncertainty across the country. I, fully vaccinated, still wore my mask at the grocery store yesterday, and was surprised when one-third of the customers and the cashiers were not wearing theirs! Initially, I felt familiarly critical of those not wearing masks, until I remembered the new relaxed guidelines, which my grocery store had just adopted following the CDC announcement. I realized that it may take time to give up the now familiar comfort that I experience behind that blue surgical mask.

Some key buzzwords and phrases, rarely used before 2020, rise to the surface of my pandemic memories. Which of these terms will be part of our sound bites ten years from now?

• “Flatten the curve”

• “The new normal”

• “Supply chain”

• “Personal Protective Equipment or PPE”

• “Essential workers”

• “Social distancing”

• “Vaccine hesitancy”

Flattening the Curve

We all became familiar with the “Flatten the Curve” diagram, which summarized the purpose of social distancing and mask wearing. Health care system capacity was nonetheless overwhelmed numerous times in different parts of our country as mitigating protective measures were met with variable adoption. Despite this range of adopted safety measures, it does look like these measures do blunt infection and hospitalization rates overall.¹ I wonder, however, if we will pull out our masks more quickly with the next flu season or pandemic—similar to how citizens of Southeast Asian countries did post SARS breakouts in early 2020?

The New Normal

Given the quick and dramatic changes in human activity around the world, it seemed inevitable that the world could not go back to the way it was before the pandemic.² “The new normal” seems to forecast a world that will be forever changed. How much of our new Zoom culture, proliferation of telemedicine, reduced travel, working from home, and avoiding public places and large sporting events will it include? 

A new normal may challenge our fee-for-service based health care system as revenues plummeted in 2020 when we asked patients not to come to the hospital and office, and elective procedures were postponed. Even before the pandemic, the growth in health care expenditures was largely recognized as unsustainable—will the “new normal” include a health care system less dependent on fee-for-service revenues, or are we headed back to the “old normal?”

The new normal includes a heightened recognition of health care disparities. Adverse social determinants of health (SDoH) underlay not only COVID-19 infection, disease, and death, but much of the chronic disease and premature mortality in our country. We are increasingly recognizing systemic racism in our society, which includes its effect on health care access and other SDoH. I believe health systems are key in addressing these disparities.  

We are also recognizing how important yet underfunded our public health system has become. Will the new normal continue to include more funding for public health as was legislated in the Coronavirus Aid, Relief, and Economic Security (CARES) Act of 2020³ and the American Rescue Plan Act of 2021?⁴ 

Supply Chain and PPE

I never gave supply chain a thought until tissues and toilet paper were missing from stores, and surgical masks in my clinic were being rationed and reused. I don’t think that I’ll ever take supply chain issues for granted again. 

It seemed that hospital administrators most savvy about procurement and supply chain did best at protecting their health care workers with PPE. Wealthier hospitals were better able to afford the inflated prices for the equipment critical for protecting health care workers.

Our dependency on a supply chain tied to overseas manufacturers underscored the central theme of Thomas Friedman’s book, The World Is Flat.⁵

Essential Workers

Initially, I thought essential workers referred to doctors and nurses. I became much more aware that what keeps our society going is an infrastructure of hourly workers in the service sector who are often underpaid, with meager (if any) employment benefits. These same people on whom we depend daily—housekeeping, maintenance and manual laborers, waste collectors, truck drivers and transportation workers, people who work in all sectors of the food supply, including restaurant servers and grocery store clerks, and many more—frequently experience adverse SDoH, including food or housing insecurity, poor access to health care services, poverty, and under-resourced neighborhoods. When we advocated for isolation at home for those infected with COVID-19, workers without sick leave and job security could not afford to stay at home. They and their families were put at greater risk for COVID-19 and chronic diseases. I am newly appreciative of the clerks and workers in my town and of the people who provide my reliable garbage pickup every Thursday morning.

Social Distancing

Perhaps the biggest change for most of us was learning to live a life in isolation, or in close quarters with a family. We are just beginning to appreciate the impact that remote and/or no schooling has had on children.

As a long time and now part-time primary care physician—while blessed to have an academic position as well—I felt guilt when not running through a slate of 20 to 30 office patients each day. Was it as much work to see two-thirds of those patients via telemedicine? Certainly, working at home has helped my academic responsibilities; giving me back time formerly spent commuting, and the flexibility to read, write, and meet colleagues virtually, without an 8 to 5 constraint.

For others, especially parents of young children, working from home meant taking on additional responsibilities like childcare, education aide, support for elderly parents, and an extended workday. The added stress of juggling multiple priorities, including competing with children or a spouse for computer access and Wi-Fi balanced with gratitude for having a paycheck takes a toll on mental health, especially over an extended period.

Without a doubt, patients who died in hospital or nursing home, isolated from family and loved ones, and touched only by health care workers through PPE, experienced the greatest cruelty of social distancing.

Vaccine Hesitancy

Although vaccine hesitancy has been recognized since the first vaccine was developed over 200 years ago,⁶ we have learned how our robust social media technology can promote distrust, rumors, and falsehoods at literally the speed of light. Political points seemed to take precedence over facts and public health and divide Americans into sectors with divergent beliefs. Steady, transparent, and fact-based communication from our leaders, and the sustained benefit provided by the COVID-19 vaccines seem to have turned the tide as we approach 70% immunization by Independence Day next month.

What Does This Mean for Population Health?

The discipline of population health was founded on principles of change—change from a health care system to a system of health; from payment for doing to payment for outcomes; and for the betterment of our population. Change has been incremental over the past decade. The pandemic represented a transformational change. As we recover, how can we keep lessons alive, to accelerate our work to a “new normal?” One way is to keep these key sound bites in mind as we continue our move to value-based care and greater population health.

This article was published in collaboration with the Jefferson College of Population Health

Disclaimer: The views and opinions expressed are those of the author(s) and do not necessarily reflect the official policy or position of the Population Health Learning Network or HMP Global, their employees, and affiliates. Any content provided by our bloggers or authors are of their opinion and are not intended to malign any religion, ethnic group, club, association, organization, company, individual, or anyone or anything.

References:

1. Johns Hopkins University of Medicine. America is reopening. But have we flattened the curve? Accessed June 2021. https://coronavirus.jhu.edu/data/new-cases-50-states. 
2. Kaminski M, Skoufalos A. The pandemic exposes clear opportunities for population health in the United States. Popul Health Manag. 2020;23(3):207-208. doi:10.1089/pop.2020.0071 
3. Centers for Disease Control and Prevention. HHS announces CARES Act funding distribution to states and localities in support of COVID-19 response. April 23, 2020. Accessed June 2021. https://www.cdc.gov/media/releases/2020/p0423-CARES-act.html. 
4. 117^th Congress. HR 1319—American Rescue Plan Act of 2021. Accessed June 2021.https://www.congress.gov/bill/117th-congress/house-bill/1319/text. 
5. Friedman, Thomas L. The World Is Flat. Farrrar, Straus, and Giroux. New York. 2005.
6. Kaminski, M. Confronting vaccine hesitancy.  Population Health Learning Network. February 12, 2021. Accessed June 2021. https://www.managedhealthcareconnect.com/content/confronting-vaccine-hesitancy.