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Editor’s Note: Dr. Andrew Chang is a cardiologist at Stanford University Medical Center. Dr. Michele Barry is the director of the Center for Innovation in Global Health at Stanford University. The opinions expressed here are theirs. Read more reviews at CNNe.com/opinion
(CNN) – In our current time of social distancing and necessary medical triage, millions of Americans are without medical treatment, both preventive and elective. Those with pre-existing and undiagnosed chronic diseases across the country will not receive care, and some will die, from lack of care and treatment due to covid-19. Many of them will never have been infected or show no symptoms of the virus, but their neglected diseases must be taken into account when taking stock of their devastating burden on our society.
More than 800,000 Americans suffer a heart attack each year, according to the Centers for Disease Control and Prevention (CDC), which equates to approximately one case every 40 seconds. However, as Dr. Harlan Krumholz recently noted in The New York Times, doctors in Europe and the United States have been asking, “Where have all the heart attacks gone?” While covid-19 cases have increased worldwide, doctors in Italy and Spain report 40-70% reductions in admissions for major heart attacks, while cardiologists in Boston, Seattle, Minneapolis, and Cincinnati also They have surprised by the 40% decrease in presentation of patients with severe heart attacks in their hospitals.
Although it is too early to draw definitive conclusions on these numbers until more complete data becomes available, there is general concern from the cardiology community about this decline. On the one hand, optimists have postulated that people can rest more, smoke less, face fewer particles with less pollution, and avoid stressful situations due to social distancing policies, leading to fewer real heart attacks. Others, however, fear that what is really happening is that some heart patients, fearful of being exposed to the coronavirus, may be avoiding hospitals, minimizing their symptoms and staying home.
In fact, The Economist has reported that the province of Bergamo in Italy has tabulated 2,420 more deaths last month than in March 2019, but less than half of these additional deaths were listed as due to covid-19 infection. One cannot help but wonder how many of these victims were those who did not seek care for non-coronavirus diseases and died in their shelter.
It stands to reason that some of the mortality totals we attribute to covid-19 may actually be an underestimate of the true magnitude of the crisis.
Avoiding healthcare settings is not a problem unique to heart disease patients. For the roughly half a million Americans receiving biweekly dialysis for kidney failure (according to the National Institute of Diabetes and Digestive and Kidney Diseases), or the 650,000 CDC estimates are receiving chemotherapy for cancer, confinement is not an option. They require these life-saving therapies in special infusion centers or dialysis units for continued survival. However, some of these patients may choose to postpone or avoid treatment altogether to avoid contracting covid-19 in these facilities from other sick people.
Problems at the health system level also contribute to the misery of people living with chronic diseases. Newly diagnosed with cancer may experience the double anxiety of their new fatal diagnosis while experiencing delays in initiating chemotherapy, radiation therapy, and curative surgery. For those whose cancers have become too widespread and no longer respond to chemotherapy, experimental drug trials are their only hope for prolonging life. Due to covid-19, these clinical trials, which were his only chance for a miracle, are indefinitely postponed or canceled.
Additionally, the fear of contracting covid-19 from healthcare settings has led to a significant reduction in blood donations across the country. This has far-reaching implications beyond patients with cancer or hematologic disorders that require regular blood transfusions to support their blood counts. This also means that there are far fewer life-saving red blood cells, platelets, and plasma products available to surgical patients and trauma victims, who may require transfusions in the emergency department or operating room.
Even the search for provisional covid-19 treatments is creating new risks for those with chronic diseases. Hydroxychloroquine, promoted prematurely by the President as a possible antiviral advance, has a well-known side effect of increasing fatal irregular heart rhythms. Furthermore, the drug, which has not yet been shown to be effective in the treatment of coronavirus, is an important drug for the treatment of autoimmune disorders such as lupus. Patients with autoimmune diseases who have relied on hydroxychloroquine for years to manage their life-threatening conditions are now at risk of running out of the drug as it is being redirected to the coronavirus effort.
Psychiatric patients, many of whom suffer from drug and alcohol addiction and homelessness, are also a particularly vulnerable group in this pandemic. Social isolation can lead to dangerous self-medication behaviors like excessive alcohol, tobacco, and drug abuse. Domestic violence victims, trapped in their homes with their abusers, are reporting incidents at higher rates. Ominously, research has shown associations between economic recessions, threatened by this epidemic, and substantial increases in suicide.
For healthcare providers who expect these effects to last only during the pandemic, emerging reports suggest that the effects of the covid-19 crisis will continue to be felt for years after the virus’s control. Heart attack patients, if not treated promptly, can develop debilitating chronic heart failure. Psychiatrists and therapists are preparing for the wave of mental health trauma suffered by first responders and healthcare providers, many of whom will have had to watch healthy young patients and their colleagues succumb to the disease. Among those who got rid of coronavirus infection, reduced physical activity due to limited access to gyms and exercise equipment (combined with diet changes to unhealthy food options to save money) can lead to obesity and other disorders. metabolic, which may manifest as future heart attacks, strokes, and diabetic complications
When this pandemic subsides, these cases of disability and death from chronic disease are unlikely to be among the victims of covid-19, as most of them will never have contracted the virus. However, there is no doubt that the crisis contributed in some way to their suffering. To truly determine the magnitude of this disaster, it is critical that health researchers and clinicians now devote attention and funding to studying these buried cases as the data arrives, incorporating their cost into the final count of the epidemic.
Furthermore, the medical community must be prepared for a possible increase in complications of chronic non-covid-19 diseases in the weeks and months to come when the immediate threat of coronavirus infection diminishes. Only by preparing for this avalanche of collateral victims will we avoid being swept away by the second silent wave of noncommunicable diseases of the pandemic.
