Covid-19 is a tragic infection that is killing hundreds of thousands of people around the world. But it is also far more than that. It is a supernova in human history: an expanding, all-encompassing set of events and responses to them that touch every aspect of the human condition, simultaneously worsening and improving human health in myriad ways, through immediate and delayed paths.
Over the next few decades, economists, epidemiologists, public health experts, historians, philosophers, sociologists, physicians, psychologists, and others will work to untangle the interwoven threads.
Even now it takes a village just to answer what seems to be a simple question: How many people have died from Covid-19?
The answer to this deceptively simple query is extraordinarily complex. A tally of excess deaths — the number of people dying in 2020 beyond expectations from prior years — is a useful indicator, but it fails to tell the whole story. Understanding why the answer is complex will help us make better decisions going forward.
Covid-19 affects death and human health through at least four mechanisms. First is the direct effect of SARS-CoV-2, the virus that causes Covid-19. The Johns Hopkins Coronavirus Resource Center, which has been tracking Covid-19 deaths around the world, puts the toll at nearly 300,000 deaths. Although this number, largely compiled from health department reports, seems reasonably accurate, official figures tend to miss some deaths and overcount others, making the net effect on deaths directly caused by Covid-19 debatable.
A second way Covid-19 causes death is by overwhelming health care systems, such as occurred in Northern Italy and New York City, but notably not in many other places. In such cases, hospitals themselves help spread the disease, while hindering the provision of routine care. People seeking care for heart attacks, strokes, and other ailments are subjected to harmful delays, producing “extra” deaths and harm as indirect consequences of the virus.
A third way Covid-19 affects human health is via the 24-7 media coverage that makes people acutely aware of — and fearful of — the disease. Awareness and fear are powerful motivators of human behavior. Many of the behavioral changes are beneficial, as people voluntarily engage in social distancing, which slows the spread of the virus. But some of the changes are harmful to health. People with chest pain, for example, may be reluctant to seek care because they are worried about getting infected. Some get to the hospital so late in the course of heart attacks that treatments may no longer help; even worse, some die silently at home.
Anticipating a flood of Covid-19 patients, hospitals canceled nonemergency procedures and surgeries, such as colonoscopies and even surgery to remove some localized cancers. Though these tough decisions were prudent in Covid-19 hot spots, they also have adverse health consequences, not to mention harmful long-term effects on the financial stability of hospitals and physician practices.
Fear and isolation also lead to increased alcohol use, suicide and domestic violence. In locations where there are relatively few serious Covid-19 cases, these detrimental indirect effects of the response to the pandemic may be the major adverse consequences.
The fourth way Covid-19 affects human health is through public policy and responses such as mandates to close nonessential business and requirements to shelter in place. These have slowed the spread of the virus, and have also yielded countless secondary effects. Massive unemployment and economic disruption will worsen wealth disparities, a powerful driver of human health. Lockdowns deter getting routine medical care, which can be problematic. In the other direction, reduced factory production might improve health by diminishing workplace accidents and improving air quality. Even reduced access to medical care may have an upside, with reductions in harmful medical care.
The multifaceted effects of Covid-19 and responses to it mean that modeling its health effects must extend beyond tracking SARS-CoV-2 infections and deaths and also include the best estimates of health and social consequences more broadly. Though difficult, such efforts must be a major focus of future research.
Thinking about Covid-19 in this broad way can help us make better decisions.
First, policy decisions must be individualized to regions and areas. There is unlikely to be a one-size-fits-all solution, as the balance of the effects of Covid-19 will vary by community. Places with thin safety nets, such as India, may face unprecedented famine. Places with strong safety nets, such as Scandinavia, may be more resilient. Even within a single nation, such as the U.S., the impact in Oregon or Wyoming may be worlds apart from that in New York and New Jersey. These considerations will be particularly important as we step down the rungs of the ladder, and work to reopen the economy.
Second, we must recognize more explicitly that beneficial policy interventions can also bring harm. Acknowledging these unavoidable trade-offs rather than eliding them can clarify decision-making and lead to additional strategies to aid individuals and communities most harmed by Covid-19.
Third, thinking broadly emphasizes the need for interdisciplinary teams. To date, public health and infectious disease experts have justifiably taken the lead among disciplines in both communicating and influencing policy decisions. But as we move forward, more far-reaching expertise is needed. No single field has the expertise required to analyze and understand all of the impacts on human health and well-being of Covid-19 and the responses to it. Historians, psychologists, economists, and ethicists, along with physicians and scientists, have unique training and the ability to think through the unforeseen or unquantified implications of policy measures. The advisory process must be shielded from political influence as much as it possibly can to avoid motivated reasoning that seeks to absolve or condemn political figures as opposed to fostering honest appraisal.
Covid-19 will be the defining event of a generation, possibly several of them. Many of its far-reaching impacts cannot yet be known. As we organize to fight this pandemic, it’s important to keep in mind that both messaging and public policy decisions will have profound health consequences apart from those related to the infection itself.
At a time when the number of past and future deaths caused by Covid-19 — and those caused by our responses to it — remain uncertain, we should broaden the range of disciplines engaged in communicating and planning future policies to avoid being misled by overly narrow and simplistic narratives whose outcomes may not optimally promote the nation’s health.
Vinay Prasad is a hematologist-oncologist and associate professor of medicine at the Oregon Health and Science University and author of “Malignant: How Bad Policy and Bad Evidence Harm People with Cancer” (Johns Hopkins University Press, April 2020). Jeffrey S. Flier is an endocrinologist, professor of medicine, and former dean of Harvard Medical School.
It’s unfortunate that this piece essentially delivers Trumps talking points. Instead of speaking for him, why not implore him to provide the safety network for those who have to choose between working or not working(livelihoods destroyed); support to avoid the negative physical and mental health sequelae that result; creative ways and resources for hospitals, other health care providers, and other businesses to provide a safe(r) way to open up.
Most egregiously, you’re wrote this from your comfortable, adequately distanced residences/offices. As physicians that are NOT frontline COVID workers, you nevertheless have access to abundant PPE and state of the art medical care. You’re asking others without your advantages to risk their lives so you can go about living your preCOVID life.
It seems a bit shortsighted to leave out theologians in your list of consulting experts. That tells us something, does it not?
Given data consistently suggest that obesity & metabolic syndrome appear to be important risk factors, isn’t it time that academic medicine began to seriously address the basis for their explosive increase in incidence? Also, shouldn’t academic medicine be playing a much more proactive role in helping society to be appropriately prepared for potential pandemics? Why is it Bill Gates who was warning us in a TED talk seen by millions?
“Reduced factory production might improve health by diminishing workplace accidents and improving air quality.”
What’s the loss of the factory production? It’s not nothing.
“Many of the behavioral changes are beneficial, as people voluntarily engage in social distancing, which slows the spread of the virus. But some of the changes are harmful to health.”
Goes far beyond reluctance to seek medical care. Social distancing for how long? Seems the antithesis of health. FEAR is the antithesis of health.
“Massive unemployment and economic disruption will worsen wealth disparities.”
It’s not “wealth disparities;” it’s the ability (or removed responsibility?) to “earn a living” in a quaint phrase.
Agree this is the defining ~~ and unprecedented ~~ event of our lifetimes.
My concerns & questions far outrun my answers.
I suppose by your metric, people who can’t afford sufficient healthcare aren’t properly “earning a living,” and thus deserve whatever we get.
I definitely understand why so many of you want to reopen so quickly and without taking any other measures – if a bunch of poor service workers die, well, it’s their faults for not getting better jobs!
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