Physicians reckon with 'profound' impact of COVID-19
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The COVID-19 pandemic has been described by Anthony S. Fauci, MD, as “the most catastrophic acute infectious disease outbreak” in more than a century.
“More than 1.1 million COVID-19 deaths have been reported in the U.S., and nearly 7 million globally; the latter figure is likely a vast underestimate,” Fauci wrote, along with his longtime chief of staff at the National Institute of Allergy and Infectious Diseases, Gregory K. Folkers, MPH, MS, in an article published earlier this year.
Beyond the loss of life, the pandemic has had a significant impact on patient health and the practice of medicine in the U.S., according to interviews with experts. For the latest story in our “Life during COVID” series, we asked them to describe some of the most significant and lasting changes.
‘An endemic threat’
COVID-19 has changed the daily health of Americans in several ways, experts said.
“The direct impact of this virus on the health of the U.S. population has been profound, obviously — mostly experienced by older persons, people who are frail, who have underlying illnesses, who are immune compromised, but it's also affected children,” said William Schaffner, MD, professor of preventive medicine and infectious diseases at Vanderbilt University Medical Center.
“It was an historic event, and the virus still hasn't disappeared, although we've moved from pandemic to the endemic phase now,” said Schaffner, a Healio | Infectious Disease News Editorial Board Member.
As early as the first year of the pandemic, experts were already forecasting that SARS-CoV-2 would join the long list of respiratory pathogens that regularly cause illness in people, including influenza and other coronaviruses.
“It appears at present that the destiny of SARS-CoV-2 is to become endemic, as have four other human coronaviruses,” David L. Heymann, MD, professor of infectious disease epidemiology at the London School of Hygiene & Tropical Medicine and chair of WHO’s Strategic and Technical Advisory Group for Infectious Hazards, said during a WHO briefing held around a year after SARS-CoV-2 first emerged.
That means people will now have to “calculate” their personal risk for SARS-CoV-2 infection the way they do for other respiratory viruses, said Amesh A. Adalja, MD, an infectious disease, bioterrorism and emergency medicine specialist and senior scholar at the Johns Hopkins Center for Health Security.
Presumably, this will include decisions about whether to wear a mask or receive a COVID-19 booster shot, like the updated monovalent vaccines that are expected to be available in the U.S. starting this fall.
“On the positive side, more people are aware of the risk of spreading infections to others, even with little to no symptoms,” said Tom Talbot, MD, MPH, professor of medicine at Vanderbilt University School of Medicine and chief hospital epidemiologist at Vanderbilt University Medical Center. “They understand some core concepts of infection prevention, such as not to come to work if you are sick — with COVID or any contagious disease.”
Data derived from 1. Definitive Healthcare; 2. U.S. Government Accountability Office; 3. Lalani HS, et al.
Long-term health impacts
Many people are also dealing with long-term health impacts associated with the pandemic, which significantly affected the mental health of adults and children in the U.S., leading to increased rates of anxiety, depression and substance use disorder, according to the NIH, which noted that data show patients are more likely to develop mental health issues after infection with SARS-CoV-2.
According to a scientific brief released by WHO in 2022, there was a 25% increase in the global prevalence of anxiety and depression in the first year of the pandemic. Children were disproportionately at risk for suicidality and self-harming behaviors, and women were more likely than men to develop symptoms of a mental health disorder, according to the report.
The American Academy of Pediatrics and other groups have declared a national health emergency over pediatric mental health in the wake of COVID-19. Some pandemic-related challenges to pediatric mental health — like quarantines — have eased, the AAP said last year, but new ones have emerged “that threaten the well-being of youth and families.”
“These include the continued exposure to COVID-19 during in-person school attendance resulting in inconsistent attendance, the challenges and consequences of remote schooling, the increasing reliance on and use of social media for communication, vaccine refusal and questions about masking, and an overall strain on hope, resilience and perseverance,” the AAP said. “The full impact of the interruption of normative socialization and learning during critical developmental stages is yet to be realized.”
Many medical specialties are involved in the care of post-acute illnesses related to SARS-CoV-2 infection, such as long COVID and the multisystem inflammatory syndromes that have been documented in both children and adults: MIS-C and MIS-A.
According to two studies published in MMWR, although the prevalence of long COVID among people with a previously documented diagnosis of COVID-19 declined from around 19% in June 2022 to 11% in June 2023, many people reported experiencing new symptoms that began more than 6 months after the acute phase of their infection, “suggesting that the prevalence of emerging symptoms in the months after acute COVID-like illness might be considerable,” the researchers wrote.
An assessment of long COVID risks over the course of 2 years found that even people who were not hospitalized with COVID-19 faced substantial risks for continuing sequelae affecting multiple organ systems, and that people who were hospitalized experienced persistently increased risk for most sequelae at 2 years, according to results published recently in Nature Medicine.
Peter J. Hotez, MD, PhD, DSc, dean of the National School of Tropical Medicine at Baylor College of Medicine and co-director of the Texas Children’s Hospital Center for Vaccine Development, likened the long-term effects to another health crisis that emerged decades earlier.
“A surge of long COVID cases could alter medical practice much as HIV/AIDS did starting in the 1980s and 90s,” he said.
Exodus
In addition to the many health care workers who have died from COVID-19, the pandemic has worsened burnout among clinicians and precipitated an exodus of hundreds of thousands of providers from health care jobs, data show.
Infectious disease physicians have one of the highest reported rates of burnout in medicine, tying for fourth place among specialties in this year’s Medscape survey, behind emergency medicine, internal medicine and pediatrics. According to the survey, 58% of ID physicians reported experiencing burnout.
On top of caring for patients, clinicians have been overwhelmed by an avalanche of potentially practice-changing information during the pandemic and an erosion of public trust in their profession — all of which has contributed to burnout, experts have said.
An estimated 23,000 documents — around half of them research articles — were published in the first 6 months of the pandemic alone, according to an analysis of two major databases published in Scientometrics. The analysis excluded preprints, the use of which expanded during the pandemic.
The U.S. ranked No. 1 in volume of published papers, according to the analysis, and ID physicians have described the daunting task of keeping up with the large volume of new COVID-19 information.
“The generation of new medical knowledge has never been faster than it was during the peak of the COVID-19 pandemic, with new research studies, clinical analyses and other articles being published at an unprecedented pace,” said Paul Biddinger, MD, chief preparedness and continuity officer at Massachusetts General Hospital.
“There also was an enormous growth in the use of prepublication data in the clinical arena,” he said. “These changes have raised important questions about how quickly and effectively frontline clinicians can analyze the rapidly evolving literature and appropriately incorporate its conclusions into their practice.”
At the same time, there was a “growth of mistrust, a skepticism of authority, a real aversion to the acceptance of science — an almost anti-science, politicization of the response,” Schaffner said.
“These are two things” — the capacity of physicians and public health experts to respond to an outbreak, and a growing mistrust of those efforts — “that are in extraordinary conflict,” Schaffner said.
The lack of trust persists, Adalja said, particularly in medical interventions like vaccines.
“This isn’t true for all patients, but it is definitely there in a significant proportion,” he said.
Biddinger agreed that not all perceptions of medicine and public health have changed for the worse.
“For some, there has been an increased appreciation of the dedication of nurses, physicians and others in the medical system to be there when they are most needed, and an increased appreciation of the need for a scientific community capable of addressing emerging challenges with cutting-edge technology and expertise,” he said.
Hotez worries that attacks and threats on the health care workforce “could become normalized,” negatively impacting the recruitment and retention of workers.
The added work of responding to the biggest health crisis in a century contributed to more than 300,000 U.S. health care providers leaving the workforce in 2021, according to a Definitive Healthcare report, which cited the toll of the pandemic as a significant reason for the mass departure.
The two specialties most impacted by staffing shortages were internal medicine and family practice, according to the report.
“The fatigue and exhaustion and burnout of our health care workers is very real and has led to a portion of caregivers to opt out of their careers,” Talbot said. “Our ability to respond to the next infectious threat — and there will be another infectious threat — has been seriously impacted negatively.”
‘Science was revved up’
What seemed unlikely at the start of the pandemic became a reality when multiple COVID-19 vaccines were authorized for use in December 2020, less than a year after scientists in China shared SARS-CoV-2’s genetic sequence.
“When this virus burst on the scene, as I like to say, we opened up our textbooks to COVID and discovered blank pages,” Schaffner said. “We didn't know anything. The vaccine development in and of itself was a spectacular scientific achievement.”
Developing a vaccine against a known or novel pathogen traditionally takes years. The accelerated development and distribution of COVID-19 messenger RNA vaccines by Moderna and Pfizer-BioNTech was fueled by a public investment of at least $31.9 billion from the U.S. government, according to a review of NIH-funded and other U.S. government grants published this year in BMJ.
“During the pandemic, the public investment in the mRNA COVID-19 vaccine products via Operation Warp Speed was far more extensive than for any previous public product development,” the authors of the study wrote.
Researchers had been studying mRNA vaccines for decades, the CDC notes on its web page describing how COVID-19 vaccines work. In fact, according to the BMJ study, out of the nearly $32 billion in public funds that went into mRNA vaccine research, $337 million was invested in the 3 decades prior to the pandemic.
COVID-19 accelerated those efforts.
“Science was revved up,” Schaffner said, “and it's not going to be revved back down. In fact, the optimism regarding using new technologies such as mRNA in new scientific areas has been, if anything, accelerated. I think that that will remain.”
The advantages of the COVID-19 mRNA vaccines include their “great application prospects and advantages, which include [a] short development cycle, easy industrialization, simple production process, flexibility to respond to new variants, and the capacity to induce better immune response,” researchers wrote in a study published last year in Signal Transduction and Targeted Therapy.
The technology is being explored for other vaccines. The NIAID initiated a phase 1 clinical trial of three experimental mRNA HIV vaccines last year and, in May of this year, launched a phase 1 trial testing an experimental universal influenza vaccine that uses the technology. Also, in July, Moderna asked the FDA to begin reviewing its application to approve a respiratory syncytial virus vaccine candidate based on mRNA technology.
The pandemic introduced other medical innovations, “including nonprescription ‘over the counter’ infectious disease tests, mass spectrometry-based detection of COVID-19 host response, and the implementation of artificial intelligence and machine learning to identify individuals infected by” SARS-CoV-2, innovations that “will give rise to a new era of infectious disease tests extending beyond the detection of SARS-CoV-2,” researchers wrote this year in Clinical Biochemistry.
“The growth of mRNA technologies is perhaps the most obvious (advancement); however, I believe that the COVID-19 pandemic has also motivated the technology sector to grow its infectious disease diagnostic capabilities, developing technologies that can be adapted faster, and are more broadly available as new outbreaks emerge,” Biddinger said.
‘Explosion’ of telemedicine
In another advancement, studies have shown that the pandemic hastened the growth and popularity of telemedicine as an alternative means for patients to access care.
“Telemedicine was already on the upswing [but] the pandemic catapulted it to standard of care for many conditions,” Adalja said.
Data from more than 16 million people with Medicare or commercial insurance demonstrated telemedicine’s rise early in the pandemic, showing that it accounted for around 30% of outpatient visits from January to June 2020, researchers reported in Health Affairs.
Although Medicaid beneficiaries in most states already had the option to use telemedicine services when the pandemic struck, Medicare recipients were limited by law to using it only in certain circumstances, according to the U.S. Government Accountability Office (GAO). That changed when HHS, in response to the pandemic, waived some Medicare restrictions to accessing remote care.
Telemedicine use skyrocketed among beneficiaries of both government programs starting in the first months of the pandemic, according to data published by the GAO. Use among Medicaid recipients increased 15-fold from March 2020 to February 2021 compared with the previous year, accounting for 32.5 million individual patient services. It increased more than 10-fold among Medicare recipients from April to December 2020 compared with the same period in 2019, totaling 53 million services, the GAO found.
“The explosion in the use of telemedicine revealed that there are many circumstances where both patients and providers appreciate the advantages of the technology,” Biddinger said. “There are, of course, circumstances where telemedicine is inferior to in-person visits, depending on the medical specialty, the type of complaint and the urgency of the evaluation. We have learned a lot in the past 3 years about how to best identify the types of medical encounters that are best suited to telemedicine.”
Experts agreed that telemedicine will likely remain as an alternative to in-person health care visits beyond the pandemic.
“We can’t go back on that,” said Trini A. Mathew, MD, MPH, associate professor of internal medicine at Oakland University William Beaumont School of Medicine in Auburn Hills, Michigan — although several expressed a desire to see improvements to ensure that everyone has equal access to it.
“It has made it easier to reach many patients who may live far away from health care organizations, but if it is here to stay, I hope that there are also infrastructure improvements that make it so that people from minoritized communities with limited access to internet and mobile devices will also have access, because these are the folks who may most benefit from flexible health care delivery options,” said Jasmine R. Marcelin, MD, associate professor of infectious diseases and vice chair of equity and inclusive excellence at the University of Nebraska Medical Center.
‘Unveiling’ inequities
COVID-19’s disproportionate impact on some populations in the U.S. has helped shine a light on racial and ethnic disparities in health care that have existed for a long time, experts said.
“The pandemic was certainly impactful in unveiling the inequities in health care caused by structural racism,” she said.
Data from nearly 50,000 patients diagnosed with COVID-19 during a 5-month period in 2020 showed that the risk for infection, hospitalization and ICU-level care was lowest for white patients in each instance compared with Hispanic, Black or African American, Asian and Pacific Islander patients.
Inequities persisted once patients had access to vaccines and treatments, leading to “more discussions about the structural reasons for those inequities,” Marcelin said.
“It was heartening to see concerted efforts to address these to protect minoritized communities, like the COVID-19 vaccine effort in the Navajo Nation, but in other cases, there is still quite a mountain to climb to move from acknowledging disparities to mitigating them,” she said.
A survey of more than 1.1 million U.S. patients revealed that a significantly higher percentage of patients who were not white reported poor health care experiences related to discrimination during the pandemic, and that respondents who reported poor experiences were less likely to be vaccinated against COVID-19, according to results published in MMWR this past May.
“It was inspiring to see how quickly research and development could be mobilized worldwide to develop vaccines with a common goal of protecting the citizens of the world, but it was disappointing to see that despite this inspiring innovation, there were still disparities in access,” Marcelin said.
According to Biddinger, the increased visibility of health care inequities in the U.S. could change the way the country prepares for emergencies.
“We have long known that disasters disproportionately affect the most vulnerable in society, but the dramatically disproportionate racial, ethnic and economic disparities in illness and the COVID-19 pandemic were especially stark,” Biddinger said.
“In many circles, this has led to discussions of reframing our approach to equity in disasters,” he said. “Instead of developing disaster plans for the general population, then adapting them to consider vulnerable populations, many people are arguing to begin with planning for those who are especially vulnerable to disaster, then generalize those plans to care for the whole of the community.”
“I think people are finally, at least at some level, talking about it,” said Mathew.
She hopes that scientists, policymakers and funders will address health care inequities beyond the pandemic to “not leave anyone behind.”
“I would hope — although I have all my fingers and toes crossed — that it will lead to a greater appreciation of how we have to improve our health care system,” Shaffner said.
References:
- American Academy of Pediatrics. Interim guidance on supporting the emotional and behavioral health needs of children, adolescents, and families during the COVID-19 pandemic. https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/interim-guidance-on-supporting-the-emotional-and-behavioral-health-needs-of-children-adolescents-and-families-during-the-covid-19-pandemic/. Last updated Sept. 10, 2022. Accessed Aug. 28, 2023.
- Bowe B, et al. Nat Med. 2023;doi:10.1038/s41591-023-02521-2.
- CDC. Understanding how COVID-19 vaccines work. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/how-they-work.html. Updated May 12, 2023. Accessed Aug. 24, 2023.
- Definitive Healthcare. Addressing the healthcare staffing shortage. https://www.definitivehc.com/resources/research/healthcare-staffing-shortage. Published October 2022. Accessed Aug. 24, 2023.
- Elam-Evans LD, et al. MMWR Morb Mortal Wkly Rep. 2023;doi:10.15585/mmwr.mm7216a5.
- Fang E, et al. Signal Transduct Target Ther. 2022;doi:10.1038/s41392-022-00950-y.
- Fauci AS, Follkers GK. J Infect Dis. 2023;doi:10.1093/infdis/jiad095.
- Ford ND, et al. MMWR Morb Mortal Wkly Rep. 2023;doi:10.15585/mmwr.mm7232.
- Lalani HS, et al. BMJ. 2023;doi:10.1136/bmj-2022-073747.
- Medscape. US physicians burnout & depression report. https://www.medscape.com/slideshow/2023-lifestyle-burnout-6016058?icd. Published Jan. 27, 2023. Accessed Aug. 24, 2023.
- Montoy JCC, et al. MMWR Morb Mortal Wkly Rep. 2023;doi:10.15585/mmwr.mm7232a2.
- Nau C, et al. Ann Intern Med. 2021;doi:10.7326/M20-8283.
- NIH. COVID-19 topics – Mental health. https://covid19.nih.gov/covid-19-topics/mental-health. Updated March 20, 2023. Accessed Aug. 25, 2023.
- Patel SY, et al. Health Affairs. 2021;doi:10.1377/hlthaff.2020.01786.
- Teixeira da Silva JA, et al. Scientometrics. 2023;doi:10.1007/s11192-020-03675-3.
- Tran NK, et al. Clin Biochem. 2023;doi:10.1016/j.clinbiochem.2021.12.011.
- U.S. Government Accountability Office. Telehealth in the pandemic — How has it changed health care delivery in Medicaid and Medicare. https://www.gao.gov/blog/telehealth-pandemic-how-has-it-changed-health-care-delivery-medicaid-and-medicare. Published Sept. 29, 2022. Accessed Aug. 22, 2023.
- COVID-19 pandemic triggers 25% increase in prevalence of anxiety and depression worldwide. https://www.who.int/news/item/02-03-2022-covid-19-pandemic-triggers-25-increase-in-prevalence-of-anxiety-and-depression-worldwide. Published March 2, 2022. Accessed Aug. 28, 2023.
For more information:
Amesh A. Adalja, MD, can be reached at aadalja1@jhu.edu.
Paul Biddinger, MD, can be reached at pbiddinger@partners.org.
Peter J. Hotez, MD, PhD, DSc, can be reached at hotez@bcm.edu.
Jasmine R. Marcelin, MD, can be reached at jasmine.marcelin@unmc.edu.
Trini A. Mathew, MD, MPH, can be reached at trini.mathew@beaumont.org.
William Schaffner, MD, can be reached at william.schaffner@vumc.org.
Tom Talbot, MD, MPH, can be reached at tom.talbot@vumc.org.
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