As has been widely discussed over the past year, pandemics have always brought about dramatic social, economic, and technological change to the societies which they have cruelly decimated. Between 1347 and the early 1350s, the Black Death claimed the lives of almost half of Europe’s population. Yet, within the death and despair of the plague, the seeds of the Renaissance were planted, and rudimentary, evidence-based public health measures began to be applied. The city of Venice was among the first to implement the “quarentena,” a forty day period of isolation of ships and people prior to entering the city to determine if individuals coming into Venice carried the plague. The public health measures of quarantine, social distancing, and face coverings have been consistently validated through the centuries. But each ensuing pandemic response has been undermined by the political and religious zealots of the day who either skipped or failed science classes.
As a consequence of the Bubonic plague in the 14th century, a profound labor shortage allowed downtrodden serfs to command more reasonable wages and to own property, thereby creating a new middle class. Concurrent agricultural and scientific breakthroughs added to economic prosperity for a larger subset of the population, even as the arts also prospered. The legacy of COVID-19 has yet to be determined, but our social, educational, and business transactions will forever be radically transformed. A year ago, after we initially hurled expletives at the computer, familiar faces suddenly appeared in the Zoom matrix. Now we greet each other with “you’re on mute” instead of “good morning,” We all took pride in our temporary mastery of technology, as business associates, friends, and family appeared on screens, with the occasional welcome intrusion of pets and young children. Classes continued, work got done and family connections were maintained by those lucky enough to have internet access or smart phones. And some things really never changed. Those who were perpetually late to in-person meetings now arrive late to Zoom conferences.
On the downside, the misery of COVID-19 has unveiled significant racial and ethnic healthcare inequities. African Americans, Latinos, and Native Americans are three times more likely than Whites to contract COVID-19, and twice as likely to die from it. The reasons for these disparities are many, but are generally centered upon the social determinants of health. Access to quality healthcare, education, nutritious food and economic stability are all critical to the mitigation of disease. It is also clear that women have disproportionately suffered in this pandemic, bearing the brunt of job loss and remote education of children. As the pandemic has brought issues of health inequity and systemic racism into sharper focus, one can only hope that full recognition of our flaws as a nation will be the first step towards serious remediation of these problems.
Sustained momentum of the Black Lives Matter movement and the passage of the 1.9 trillion dollar COVID-19 Relief Bill are critical to our national, moral and economic recovery, as is the lending of support to the American people with funding for vaccines and testing, schools, housing, childcare, ACA premiums, and aid to state and local governments. There is a sense of hope that all of this has transpired in a legislative environment so consistently contaminated by the spittle of Republican ideologues and rabid Fox commentators. The practice of medicine will be forever changed by the pandemic, though it is still unclear whether the benefits of research and new technologies will ultimately counter the downside of impersonal and fragmented care. COVID-19 is a monster with a hundred disguises, which ripped through our country in a heartless and chaotic fashion. Infected individuals suffered along the spectrum from minimal illness to prolonged disability or death, and the financial and emotional tolls endured by surviving family members are unfathomable. We have made progress in the management of COVID-19 only through experience and the discipline of scientific method to determine which treatments help and which might hinder recovery.
mRNA technologies existed before the pandemic, but the application of these methodologies to create two effective vaccines in less then a year is nothing short of miraculous. These vaccines, as well as others built upon more traditional vaccine platforms, have the potential to snuff out the pandemic within the next few months if distributed widely in the context of ongoing public health measures. Progress is being made in spite of, not because of, the previous administration’s boasting. The hangover of Trump’s presidency continues to pound in the heads of public health officials and researchers as they vigorously dispute the lifting of mask mandates and limits upon gatherings in the dangerous interval between the ascent of viral mutations and full herd immunity. Another technology which existed before the pandemic, but rose into prominence early in the lock down, is telemedicine. Hospitals and medical providers at all levels were quick to adopt telemedicine in order to maintain critical contact with patients. This technology will become a mainstay of medical care going forward, keeping those who are homebound or lacking in transportation in touch with their healthcare providers. The addition of refined artificial intelligence algorithms might further enhance the overall diagnostic and therapeutic value of telemedicine visits.
Yet, there has been widespread abuse of this technology in the for-profit world of medicine. A number of start ups have skirted the rules governing state medical licensure to offer “convenience” prescription drugs (for ED, hair loss, herpes, birth control) by mail after a remote visit with a healthcare provider who hasn’t the foggiest notion your complete medical history or who you are. Some are even promoting themselves as your new primary care physician squeezed into a smart phone. Seems convenient, doesn’t cost much, so what could possibly go wrong? Plenty, as it turns out. During my 30 plus years of practice as a family physician, there were countless times when office visits for routine problems evolved into complex, life threatening challenges. Telemedicine cannot do justice to the crucial role of the physical exam. A trained eye might discover an incidental melanoma, a carefully applied stethoscope may reveal heart failure or pneumonia, and a sensitive nose might pick up the musty smell of strep or the sweet smell of early ketoacidosis in diabetics. We may well be entering a dangerous new era of missed cancer screening, delayed routine immunizations, and other foregone opportunities due to over reliance on telemedicine. Add to that a shaky sense of empowerment offered to patients who can now receive lab testing according to their own internet inspired inclinations, leading ultimately to increases in costs, confusion about the results and delayed diagnosis.
Going forward, we will need to optimize the balance of office/hospital visits with virtual visits, a dynamic balance which will be constantly evolving along with technology and the structure of the medical work force. We will need true universal healthcare coverage to enhance access, and ongoing review of what works and what doesn’t work in order to optimize outcomes and control costs in our highly profit driven corporate medical world. We have learned a lot about health inequities, virology, public health, new technologies, and the vital necessity of working together over the past year. Let’s not squander this knowledge as we deal with this pandemic and others which will inevitably occur in the future.
(Robert S. Kiefner is a retired family physician who lives in Concord)
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