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Tag: health-care workers

  • A nurse's fatal last visit to patient's home renews calls for better safety measures

    A nurse's fatal last visit to patient's home renews calls for better safety measures

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    WILLIMANTIC, Conn. (AP) — The killing of a Connecticut nurse making a house call in October was a nightmare come true for an industry gripped by the fear of violence.

    Already stressed out by staffing shortages and mounting caseloads, heath care workers are increasingly worrying about the possibility of a patient becoming violent – a scenario that is too common and on the rise nationwide.

    Joyce Grayson, a 63-year-old mother of six, went into a halfway house for sex offenders in late October, to give medication to a man with a violent past. She didn’t make it out alive.

    Police found her body in the basement and have named her patient as the main suspect in her killing.

    Grayson’s death has her peers and lawmakers renewing their yearslong pleas for better protections for home health care workers, including sending them out with escorts and providing more information about their patients. The calls come during an era of increasing violence against medical professionals in general.

    “I used to go into some pretty bad neighborhoods,” said Tracy Wodatch, a visiting nurse and chief executive of the Connecticut Association of Healthcare at Home. She said she used to call the police and get an officer to escort her when she felt unsafe. But, because of budget and staffing issues, this is no longer an option, she said.

    Grayson, who had been a nurse for over 36 years including the last 10 as a visiting nurse, was found dead Oct. 28 in the Willimantic halfway house. She didn’t return from a visit to patient Michael Reese, a convicted rapist. No charges have been filed in the killing yet.

    “It’s all nurses are thinking about right now, even the hospital nurses because they’ve had so many close calls,” said Connecticut state Sen. Martha Marx, a visiting nurse and New London Democrat who is calling for changes in both state and federal laws.

    Marx said she was once sent to a home and didn’t find out until she talked to clients there that it was a residence for sex offenders. Often, if a nurse asks for a chaperone, the agency will simply reassign the work to another employee who won’t “make waves,” she said.

    Grayson’s death came about 11 months after another visiting nurse, Douglas Brant, was shot to death during a home visit in Spokane, Washington — a killing that also drew calls for safety reforms, including federal standards on preventing workplace violence.

    While killings are rare, nursing industry groups say non-fatal violence against health care workers is not. From 2011 to 2018, the rate of non-fatal violence against health care workers increased more than 60%, according to the latest analysis by the federal Bureau of Labor Statistics.

    In fact, the number of non-fatal injuries from workplace violence involving health care workers has been higher than that of other industries for years, according to the bureau.

    In a survey released in late 2022 by the National Nurses United, the largest union of registered nurses in the U.S., 41% of hospital nurses reported an increase in recent workplace violence incidents, up from 30% in September 2021.

    “I knew a home health aide who got punched in the stomach,” said Ha Do Byon, a former visiting nurse and now a nursing professor at the University of Virginia, who has been studying violence against home health care workers. “Many more nurses got bitten, kicked, or slapped by their patients or family members in the patients’ homes. Some were attacked by vicious dogs or were called names or sworn at. Notably, the majority of these workers were female.”

    Byon said specific statistics on visiting nurses has been lacking and he has been working on improving the data.

    “There’s no way home health workers should be sent into somebody’s home or apartment by themselves,” said U.S. Rep. Joe Courtney, a Democrat who represents the congressional district where Grayson was killed. “You have to have systems and tools to reduce the risk.”

    Courtney has been pushing legislation since 2019 that would set up federal regulations requiring health care and social service employers to develop and implement comprehensive workplace violence prevention plans. While several states require such prevention plans, there is no federal law, industry groups say.

    He says the problem highlighted by Grayson’s case is not just about safety, but also about attracting and retaining health care workers, many of whom feel the job is just too dangerous.

    “It’s honestly a huge factor in terms of the burnout that employers are so concerned about, ” Courtney said.

    Marx wants to see laws requiring security escorts for nurses in some cases, and for police to provide caregivers regularly updated lists of addresses where violent crime has occurred. She also said patients’ charts should be flagged to alert nurses about past incidents of violence, if they’re registered sex offenders and other information.

    Grayson was a nurse for the Connecticut Department of Mental Health and Addiction Services for 26 years before serving as a visiting nurse for over a decade, according to her family. She also was a beloved foster parent, taking in nearly three dozen children and being honored with the state’s Foster Parent of the Year award in 2017.

    What exactly Grayson knew about Reese and the halfway house in Willimantic is one of many unanswered questions in the case.

    Her employer, Elara Caring, said Grayson had Reese’s medical file before she went there, but it declined to say what information was in the file, citing medical privacy laws.

    Elara, which provides home care for more than 60,000 patients in 17 states, says it is reviewing its safety protocols and talking to employees about what more is needed. Scott Powers, chairman and chief executive, said company workers were shocked and grieving over Grayson’s death.

    The company said it had safeguards in place when Grayson was killed. This includes working with states to ensure patients, including ex-cons, are deemed safe by state officials to be cared for in the community and training for employees to prepare them for such clients. It declined to go into deeper details about its security protocols, citing the investigation into Grayson’s death.

    Police still haven’t said how Grayson died, and the medical examiner’s office said autopsy results remain pending. Willimantic’s police chief, Paul Hussey, called the killing one of the worst cases he has seen in his 27 years in law enforcement.

    Reese, who was on probation after serving more than 14 years in prison for stabbing and sexually assaulting a woman in 2006 in New Haven, was taken into police custody while leaving the halfway house on the day Grayson was killed. He was released from prison in late 2020 and was sent back to detention two times for violating probation, state records show.

    Authorities said he had some of Grayson’s belongings, including credit cards, and was charged with violating probation, larceny and using drug paraphernalia. He is detained on $1 million bail. A public defender listed in court records as representing Reese did not return emails seeking comment.

    Grayson’s family is devastated and is seeking answers to an array of questions, including if there were failures of oversight by the state Department of Correction, state probation officials and the company that runs the halfway house. They also want to know whether Elara Caring adequately protected her, according to their lawyer, Kelly Reardon, who said a lawsuit is planned.

    “They were extremely concerned that it was preventable,” Reardon said. “They certainly felt from the get-go that there were failings in the system that led to this and they want that to be investigated.”

    ____

    Collins reported from Hartford, Connecticut.

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  • Sick Season Will Be Worse From Now On

    Sick Season Will Be Worse From Now On

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    Last fall, when RSV and flu came roaring back from a prolonged and erratic hiatus, and COVID was still killing thousands of Americans each week, many of the United States’ leading infectious-disease experts offered the nation a glimmer of hope. The overwhelm, they predicted, was probably temporary—viruses making up ground they’d lost during the worst of the pandemic. Next year would be better.

    And so far, this year has been better. Some of the most prominent and best-tracked viruses, at least, are behaving less aberrantly than they did the previous autumn. Although neither RSV nor flu is shaping up to be particularly mild this year, says Caitlin Rivers, an epidemiologist at the Johns Hopkins Center for Health Security, both appear to be behaving more within their normal bounds.

    But infections are still nowhere near back to their pre-pandemic norm. They never will be again. Adding another disease—COVID—to winter’s repertoire has meant exactly that: adding another disease, and a pretty horrific one at that, to winter’s repertoire. “The probability that someone gets sick over the course of the winter is now increased,” Rivers told me, “because there is yet another germ to encounter.” The math is simple, even mind-numbingly obvious—a pathogenic n+1 that epidemiologists have seen coming since the pandemic’s earliest days. Now we’re living that reality, and its consequences. “What I’ve told family or friends is, ‘Odds are, people are going to get sick this year,’” Saskia Popescu, an epidemiologist at the University of Maryland School of Medicine, told me.

    Even before the pandemic, winter was a dreaded slog—“the most challenging time for a hospital” in any given year, Popescu said. In typical years, flu hospitalizes an estimated 140,000 to 710,000 people in the United States alone; some years, RSV can add on some 200,000 more. “Our baseline has never been great,” Yvonne Maldonado, a pediatrician at Stanford, told me. “Tens of thousands of people die every year.” In “light” seasons, too, the pileup exacts a tax: In addition to weathering the influx of patients, health-care workers themselves fall sick, straining capacity as demand for care rises. And this time of year, on top of RSV, flu, and COVID, we also have to contend with a maelstrom of other airway viruses—among them, rhinoviruses, parainfluenza viruses, human metapneumovirus, and common-cold coronaviruses. (A small handful of bacteria can cause nasty respiratory illnesses too.) Illnesses not severe enough to land someone in the hospital could still leave them stuck at home for days or weeks on end, recovering or caring for sick kids—or shuffling back to work, still sick and probably contagious, because they can’t afford to take time off.

    To toss any additional respiratory virus into that mess is burdensome; for that virus to be SARS-CoV-2 ups the ante all the more. “This is a more serious pathogen that is also more infectious,” Ajay Sethi, an epidemiologist at the University of Wisconsin at Madison, told me. This year, COVID-19 has so far killed some 80,000 Americans—a lighter toll than in the three years prior, but one that still dwarfs that of the worst flu seasons in the past decade. Globally, the only infectious killer that rivals it in annual-death count is tuberculosis. And last year, a CDC survey found that more than 3 percent of American adults were suffering from long COVID—millions of people in the United States alone.

    Read: Is COVID a common cold yet?

    With only a few years of data to go on, and COVID-data tracking now spotty at best, it’s hard to quantify just how much worse winters might be from now on. But experts told me they’re keeping an eye on some potentially concerning trends. We’re still rather early in the typical sickness season, but influenza-like illnesses, a catchall tracked by the CDC, have already been on an upward push for weeks. Rivers also pointed to CDC data that track trends in deaths caused by pneumonia, flu, and COVID-19. Even when SARS-CoV-2 has been at its most muted, Rivers said, more people have been dying—especially during the cooler months—than they were at the pre-pandemic baseline. The math of exposure is, again, simple: The more pathogens you encounter, the more likely you are to get sick.

    A larger roster of microbes might also extend the portion of the year when people can expect to fall ill, Rivers told me. Before the pandemic, RSV and flu would usually start to bump up sometime in the fall, before peaking in the winter; if the past few years are any indication, COVID could now surge in the summer, shading into RSV’s autumn rise, before adding to flu’s winter burden, potentially dragging the misery out into spring. “Based on what I know right now, I am considering the season to be longer,” Rivers said.

    With COVID still quite new, the exact specifics of respiratory-virus season will probably continue to change for a good while yet. The population, after all, is still racking up initial encounters with this new coronavirus, and with regularly administered vaccines. Bill Hanage, an epidemiologist at Harvard’s T. H. Chan School of Public Health, told me he suspects that, barring further gargantuan leaps in viral evolution, the disease will continue to slowly mellow out in severity as our collective defenses build; the virus may also pose less of a transmission risk as the period during which people are infectious contracts. But even if the dangers of COVID-19 are lilting toward an asymptote, experts still can’t say for sure where that asymptote might be relative to other diseases such as the flu—or how long it might take for the population to get there. And no matter how much this disease softens, it seems extraordinarily unlikely to ever disappear. For the foreseeable future, “pretty much all years going forward are going to be worse than what we’ve been used to before,” Hanage told me.

    Read: The next stage of COVID is starting now

    In one sense, this was always where we were going to end up. SARS-CoV-2 spread too quickly and too far to be quashed; it’s now here to stay. If the arithmetic of more pathogens is straightforward, our reaction to that addition could have been too: More disease risk means ratcheting up concern and response. But although a core contingent of Americans might still be more cautious than they were before the pandemic’s start—masking in public, testing before gathering, minding indoor air quality, avoiding others whenever they’re feeling sick—much of the country has readily returned to the pre-COVID mindset.

    When I asked Hanage what precautions worthy of a respiratory disease with a death count roughly twice that of flu’s would look like, he rattled off a familiar list: better access to and uptake of vaccines and antivirals, with the vulnerable prioritized; improved surveillance systems to offer  people at high risk a better sense of local-transmission trends; improved access to tests and paid sick leave. Without those changes, excess disease and death will continue, and “we’re saying we’re going to absorb that into our daily lives,” he said.

    And that is what is happening. This year, for the first time, millions of Americans have access to three lifesaving respiratory-virus vaccines, against flu, COVID, and RSV. Uptake for all three remains sleepy and halting; even the flu shot, the most established, is not performing above its pre-pandemic baseline. “We get used to people getting sick every year,” Maldonado told me. “We get used to things we could probably fix.” The years since COVID arrived set a horrific precedent of death and disease; after that, this season of n+1 sickness might feel like a reprieve. But compare it with a pre-COVID world, and it looks objectively worse. We’re heading toward a new baseline, but it will still have quite a bit in common with the old one: We’re likely to accept it, and all of its horrors, as a matter of course.

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    Katherine J. Wu

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  • A Simple Marketing Technique Could Make America Healthier

    A Simple Marketing Technique Could Make America Healthier

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    This article was originally published in Knowable Magazine.

    Death from colorectal cancer can be prevented by regular screenings. Controlling high blood pressure could prolong the lives of the nearly 500,000 Americans who die from this disease each year. Vaccinations help prevent tetanus, which could otherwise be lethal.

    Clearly, preventive medicine can make a big difference to health.

    And yet most people don’t get the preventive care that could save their lives. Indeed, as of 2015, only 8 percent of U.S. adults 35 and older had received all immunizations, cancer screenings, and other high-priority services recommended for them.

    Researchers seeking to change that are borrowing a page from Facebook, Google, and other tech companies. By rapidly comparing small differences in how they communicate with patients—a process known as A/B testing—health-care workers can quickly learn what works and what doesn’t. The approach has already delivered several actionable improvements, though not everyone is convinced of its value.

    Tech-oriented companies use A/B testing to make decisions about marketing slogans, web-page colors, and lots of other options. The key is randomization, meaning that people are randomly assigned to see different versions of whatever is being tested. Does a bigger “Subscribe” button on a website generate more clicks than a smaller one? Does one headline over a story capture more readers than another?

    Read: There’s no such thing as a casual interaction with your doctor anymore

    Leora Horwitz, an internist and a health-services researcher at NYU Langone Health, and her colleagues adopted this technique—which they call rapid randomized controlled trials—to learn how to improve the delivery of health-care services. Randomized controlled trials, or RCTs, are widely used in medicine, typically to test new drugs or other disease treatments. For example, patients may be randomly assigned to receive either a new drug or the current standard treatment, then followed for months or years to assess whether the new drug works better. But those trials are slow and expensive, in part because researchers have to recruit people willing to be in a medical experiment.

    Rapid RCTs, by contrast, are not used to study new treatments, so nobody has to be recruited to participate. Rather, Horwitz’s goal is to improve health-care delivery through quick trials in which one can repeatedly test and fine-tune changes to health-care delivery based on what researchers learn from each test.

    “We are randomizing what we’re doing so that we can quickly and accurately assess whether what we are doing is working,” says Horwitz, who wrote about the approach in the 2023 Annual Review of Public Health.

    For example, Horwitz and her colleagues wanted to figure out how to get patients to book appointments to address care gaps—preventive services that are overdue. Because of the huge number of patients, physicians’ offices can’t contact everyone by telephone or through the online portal that NYU Langone uses to communicate with patients. So the health system needed to understand what type of reminders were most effective.

    In the A/B test, patients with care gaps were divided into two sets: those who had signed up for an online-portal account and those who had not. Patients in each set were then sorted into different groups based on their health-care history. Patients who, based on past behavior, were unlikely to initiate appointments on their own were put in higher-risk groups; those who had eventually booked their own appointments in the past were assigned to lower-risk groups.

    In one part of the test, several thousand patients who had no portal account were randomized so that some received a telephone-call reminder and others did not. Patients who received a phone call booked appointments to address 6.2 percent of the care gaps, compared with just 0.5 percent among those who were not called.

    In another part of the test, some patients with portal accounts received a reminder message through that channel, while others did not. Of those who received the message, 13 percent scheduled the needed services, compared with 1.1 percent of those who were not contacted.

    Importantly, the experiments revealed that a phone-call reminder was the most effective way to reach the subgroups of patients who were high-risk and the least likely to get their preventive services without a nudge. Shortly after the test results were known, NYU Langone prioritized all of its highest-risk patients to receive telephone reminders and greatly expanded its capacity for sending messages through the patient portal.

    “When we learn something, we apply that to all of our messaging quickly,” Horwitz says. That immediately extends what they’ve learned to tens of thousands of people. “That’s gratifying.”

    Read: Do you really want to read what your doctor writes about you?

    NYU Langone’s A/B testing is why many of the medical center’s female patients are now receiving short messages to remind them to schedule their mammograms. The researchers used rapid RCTs to test the wording on reminders sent through the online portal: Would shorter messages get better results? Indeed, patients who received a 78-word reminder scheduled nearly twice as many mammograms as those who received the old 155-word message.

    In another investigation, to find out how to boost vaccination rates among very young children, Horwitz and her team turned to rapid randomized tests that compared one-text and two-text reminders to parents against no text reminder at all. Only the two-text reminder—one sent at 6 p.m., the other sent at noon two days later—made a difference, tripling the number of appointments scheduled. Most appointments were made after the second text, suggesting that this booster reminder was what triggered the parents to act.

    Though it’s still new to the health-care sector, the idea of rapid RCTs is catching on. One research team—an economist, a physician, and a public-policy expert, none of whom was affiliated with Horwitz’s group—used the technique to learn how to increase the use of preventive-care services by Black men, the U.S. demographic group with the lowest life expectancy.

    They recruited more than 1,300 Black men from Oakland, California–area barbershops and flea markets, asked them to fill out a health questionnaire, and gave them a coupon for a free health screening. A pop-up clinic, staffed with 14 Black and non-Black male doctors, was set up to provide the screenings, and the participating men were randomly assigned to a Black or a non-Black doctor. The result: Black men assigned to Black physicians were more likely to get diabetes screenings, flu vaccinations, and other preventive services than those assigned to non-Black doctors.

    Some experts doubt that rapid A/B testing will ever become commonplace in health care. Darren DeWalt, a physician who directs the Institute for Healthcare Quality Improvement at the University of North Carolina, likes the concept, but he thinks most health-care organizations will avoid it for ethical reasons, possibly because people tend to disapprove of randomization, even in the context of something as innocuous as appointment reminders. “People in this country don’t like the idea that they are randomly allocated to something, even something as simple as that,” DeWalt says. “There’s a lot of suspicion around researchers in health care.”

    Others criticize A/B testing as tinkering at the margins. Pierre Barker, the chief scientific officer for the nonprofit Institute for Healthcare Improvement in Boston, believes that significant improvements in health-care delivery require an in-depth analysis of the problem to be solved, which may require many changes to the system. By contrast, rapid randomized controlled trials focus on a single, discrete change—say, the words used in a telephone script—rather than a broader effort to understand why patients don’t get preventive services and what can be done to change that.

    “The attractiveness is how fast it can move, more than the size of the impact,” he says. “I remain to be convinced that you can get more than a small incremental change” from rapid randomized controlled trials.

    It is true that the majority of NYU Langone’s care gaps were not resolved by the new reminders, says Horwitz, but the tests did provide information that led to hundreds of potentially lifesaving services being performed. That is what convinces her that the health-care industry should embrace rapid randomized trials.

    “If you were working for a web company or an airline or any other industry, you would randomize as a matter of course—this is the standard practice,” she says. “But it is still very foreign in health care, and it shouldn’t be.”

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    Lola Butcher

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  • Is the Worst of Winter Over for COVID?

    Is the Worst of Winter Over for COVID?

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    For months, the winter forecast in the United States seemed to be nothing but viral storm clouds. A gale of RSV swept in at the start of autumn, sickening infants and children in droves and flooding ICUs. After a multiyear hiatus, flu, too, returned in force, before many Americans received their annual shot. And a new set of fast-spreading SARS-CoV-2 subvariants had begun its creep around the world. Experts braced for impact: “My biggest concern was hospital capacity,” says Katelyn Jetelina, who writes the popular public-health-focused Substack Your Local Epidemiologist. “If flu, RSV, and COVID were all surging at the same time—given how burned out, how understaffed our hospital systems are right now—how would that pan out?”

    But the season’s worst-case scenario—what some called a “tripledemic,” bad enough to make health-care systems crumble—has not yet come to pass. Unlike last year, and the year before, a hurricane of COVID hospitalizations and deaths did not slam the country during the first month of winter; flu and RSV now appear to be in sustained retreat. Even pediatric hospitals, fresh off what many described as their most harrowing respiratory season in memory, finally have some respite, says Mary Beth Miotto, a pediatrician and the president of the Massachusetts chapter of the American Academy of Pediatrics. After a horrific stint, “we are, right now, doing okay.” With two months to go until spring, there is plenty of time for another crisis to emerge: Certain types of influenza, in particular, can be prone to delivering late-season second peaks. “We need to be careful and recognize we’re still in the middle,” Jetelina told me. But so far, this winter “has not been as bad as I expected it to be.”

    No matter what’s ahead, this respiratory season certainly won’t go down in history as a good one. Children across the country have fallen sick in overwhelming numbers, many of them with multiple respiratory viruses at once, amid a nationwide shortage of pediatric meds. SARS-CoV-2 remains a top cause of mortality, with its daily death count still in the hundreds, and long COVID continues to be difficult to prevent or treat. And enthusiasm for new vaccines and virus-blocking mitigations seems to be at an all-time low. Any sense of relief people might be feeling at this juncture must be tempered by what’s in the rearview: three years of an ongoing pandemic that has left more than 1 million people dead in the U.S. alone, and countless others sick, many chronically so. The winter may be going better than it could have. But that shouldn’t hold us back from tackling what’s ahead this season, and in others yet to come.

    Not all of this past autumn’s gloomy predictions were off base. RSV and flu each rushed in on the early side of the season and led to a steep rise in cases. But both viruses made rather hasty exits: RSV hit an apparent apex in mid-November, and flu bent into its own decline the following month. The staggered peaks “helped us quite a bit, in terms of hospitals being stressed,” says Sam Scarpino, the director of AI and life sciences at the Institute for Experiential AI at Northeastern University. In recent days, coronavirus cases and hospitalizations have been tilting downward, too—and severe-disease rates seem to be holding at a relative low. Just under 5 percent of hospital beds are currently occupied by COVID patients, compared with more than four times that fraction this time last year. And weekly COVID deaths are down by almost 75 percent from January 2022. (Death, though, has always been a lagging indicator, and the mortality numbers could still shift upward soon.) Despite some dire predictions to the contrary, the fast-spreading XBB.1.5 subvariant didn’t spark “some giant Omicron-type wave and crush everything,” says Justin Lessler, an infectious-disease modeler at the University of North Carolina at Chapel Hill. “In that sense, I feel good.”

    Read: How worried should we be about XBB.1.5?

    No one can say for sure why we dodged winter’s deadliest bullets, but the population-level immunity that Americans have built up over the past three years clearly played a major role. “That’s a testament to how vaccination has made the disease less dangerous for most people,” says Cedric Dark, an emergency physician at Baylor College of Medicine. Widespread immunization, combined with the fact that most Americans have now been infected, and many of them reinfected, has caused severe-disease rates to plunge, and the virus to move less quickly than it otherwise would have. Antiviral drugs, too, have been slashing hospitalization rates, at least for the meager fraction of recently infected people who use them. The gargantuan asterisk of long COVID still applies to new infections, but the short-term effects of the disease are now more on par with those of other respiratory illnesses, reducing the number of resources that health-care workers must marshal for each case.

    The virus, too, was more merciful than it could have been. XBB.1.5, despite its high transmissibility and penchant for dodging antibodies, doesn’t so far seem more capable of causing severe disease. And the fall’s bivalent shots, though not a perfect match for the newcomer, still improve the body’s response to viruses in the Omicron clan. Competition among respiratory viruses may have also helped soften COVID’s recent blows. In the days and weeks after one infection, bodies can become more resilient to another—a phenomenon known as viral interference that can reduce the risk of simultaneous or back-to-back infections. On population scales, interference can push down surges’ peaks, or at the very least, separate them, potentially keeping hospitals from being hit by a medley of microbes all at once. It’s hard to say for sure: “Many things go into when an epidemic wave happens—human behavior, temperature, humidity, the biology of the virus, the biology of the host,” says Ellen Foxman, an immunologist at Yale. That said, “I do think viral interference probably does play a role that has not been appreciated.”

    None of the experts I spoke with was ready to issue a blanket phew. Overlapping waves of respiratory illness have already led to nonstop sickness, especially among children, draining resources at every point in the pediatric caregiving chain. Kids were kept out of school, and parents stayed home from work; after a glut of COVID-related closures in New Mexico, schools and day cares running low on teachers had to call in the National Guard. Inundated with illnesses, pediatric emergency rooms overflowed; adult-care units had to be repurposed for children, and some hospitals pitched tents on their front lawns to accommodate overflow. Local stopgaps weren’t always enough: At one point, a colleague of Miotto’s in Boston told her that the closest available pediatric ICU bed was in Washington, D.C.

    Read: The worst pediatric-care crisis in decades

    By any metric, for the pediatric community, “it’s been a horrible season, the worst,” says Yvonne Maldonado, a pediatrician at Stanford. “The hospitals were bursting, bursting at the seams.” The flow of fevers has ebbed somewhat in recent weeks, but remains more flood than trickle. “It’s not over: We still don’t have amoxicillin in general, and we still struggle to get fever medication for people,” Miotto said. A parent recently told her that they’d gone to almost 10 pharmacies to try to fill an antibiotic prescription for their child. And pediatric providers across the country are steeling themselves for what the coming weeks could bring. “I think we could still see another surge,” says Joelle Simpson, the division chief of emergency medicine at Children’s National Hospital. “In prior years, February has been one of the worst months.”

    The season’s ongoing woes have been compounded by preexisting health-care shortages. Amid a dearth of funds, some hospitals have reduced their number of pediatric beds; a mass exodus of workers has also limited the resources that can be doled out, even as SARS-CoV-2 testing and isolation protocols continue to stretch the admission and discharge timeline. “Hospitals are in a weaker position than they were before the pandemic,” says Joseph Kanter, Louisiana’s state health officer and medical director. “If that’s the environment in which we are experiencing this year’s respiratory-virus season, it makes everything feel more acute.” Those issues are not limited to pediatrics: Now that COVID is a regular part of the disease roster, workloads have increased for a contingent of beleaguered clinicians that, across the board, seems likely to continue to shrink. In many hospitals, patients are getting stuck in emergency departments for several hours, even multiple days—sometimes never making it to a bed before being sent home. “It seems like hospitals everywhere are full,” Dark told me, not just because of COVID, but because of everything. “The vast majority of the work I do, and that I bet you what most of my colleagues are doing, is taking place in waiting rooms.”

    The U.S. has come a long way in the past three years. But still, “the cumulative toll of these winter surges has been higher than it needs to be,” says Julia Raifman, a health-policy researcher at Boston University. Had more people gone into winter up to date on their COVID vaccines, the virus’s mortality rate could have been driven down further; had more antiviral drugs and other protections been prioritized for the elderly and immunocompromised, fewer people might have been imperiled at all. If relief is percolating across the country right now, that says more about a shift in standards than anything else. “Our threshold for what ‘bad’ looks like has just gotten so out of whack,” Simpson told me. This winter could have been as grim as recent ones, Scarpino told me, with body-filled freezer trucks in parking lots and hospitals on the brink of collapse. But an improvement from those horrific lows isn’t much to brag about. And this winter—three years into combatting a coronavirus for which we have shots, drugs, masks, and more—has been nowhere close to the best one imaginable.

    The concern now, experts told me, is that the U.S. might accept a winter like this one as simply good enough. Regular vaccine uptake could dwindle even further; another wild-card SARS-CoV-2 variant could ignite another conflagration of cases. If that did happen, some researchers worry that we’d be slow to notice: Genomic surveillance is down, and many tests are being taken, unreported, at home. And with so many different immune histories now scattered across the globe, it’s getting tougher for modelers like Lessler to predict where and how quickly new variants might take over.

    The country does have a few factors working in its favor. By next winter, at least one RSV vaccine will almost certainly be available to protect the population’s youngest, eldest, or both. mRNA-based flu vaccines, which are expected to be far faster to develop than currently available shots, are also in the works, and will likely make it easier to match doses to circulating strains. And if, as Foxman hopes, SARS-CoV-2 eventually settles into a more predictable, seasonal pattern, infections will be less of a concern for most of the year and season-specific immunizations could be easier to design.

    Read: Should everyone be masking again?

    But no vaccine will do much unless enough people are willing and able to take it—and the public-health infrastructure that’s led many outreach efforts remains underfunded and understaffed. Kanter worries that the nation may not be terribly willing to invest. “We’ve fallen into this complacency trap where we just accept a given amount of mortality every year as unavoidable,” he told me. It doesn’t have to be that way, as the past few years have shown: Treatments, vaccines, clean indoor air, and other measures can lower a respiratory virus’s toll.

    By the middle of spring, the U.S. will be in a position to let the public-health-emergency declaration on COVID lapse—a decision that could roll back protections for the uninsured, and ratchet up price points on shots and antivirals. This winter’s retrospective is likely to influence that decision, Scarpino told me. But relief can breed complacency, and complacency further slows a sluggish public-health response. The fate of next winter—and of every winter after that—will depend on whether the U.S. decides to view this season as a success, or to recognize it as a shaky template for well-being that can and should be improved.

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    Katherine J. Wu

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  • Please Stop Kissing Strangers’ Babies

    Please Stop Kissing Strangers’ Babies

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    Barack Obama did it. Donald Trump did it. Joe Biden, of course, has done it too. But each of them was wrong: Kissing another person’s baby is just not a good idea.

    That rule of lip, experts told me, should be a top priority during the brisk fall and winter months, when flu, RSV, and other respiratory viruses tend to go hog wild (as they are doing right this very moment). “But actually, this is year-round advice,” says Tina Tan, a pediatrician at Lurie Children’s Hospital of Chicago. Rain, wind, or shine, outside of an infant’s nuclear family, people should just keep their mouths to themselves. Leave those soft, pillowy cheeks alone!

    A moratorium on infant smooching might feel like a bit of a downer—even counterintuitive, given how essential it is for infants and caregivers to touch. But kissing isn’t the only way to show affection to a newborn, and the rationale for cutting back on it specifically is one that most can get behind: keeping those same wee bebes safe. An infant’s immune system is still fragile and unlearned; it struggles to identify infectious threats and can’t marshal much of a defense even when it does. Annette Cameron, a pediatrician at Yale, told me she usually advises parents to avoid public places—church, buses, stores—until their baby is about six weeks old, and able to receive their first big round of immunizations. (And even then, shots take a couple of weeks to kick in.)

    The situation grows far less perilous once kids’ vaccine cards start to get more full; past, say, six months of age or so, they’re in much better shape. But risk remains a spectrum, especially when lips get involved. The mouth, I am sorry to tell you, is a weird and gross place, chock-full of saliva, half-chewed flecks of food, and microbes galore; all that schmutz is apt to drool and dribble onto whatever surfaces we drag our faces across. Flu, RSV, rhinovirus, SARS-CoV-2, and the coronaviruses that lead to common colds are among the many respiratory pathogens that hang out in and around our mouth. Although these viruses don’t usually make adults very sick, they can clobber young, unvaccinated kids, whose airways are still small. Health-care workers are seeing a lot of those illnesses now: Cameron recently treated a two-week-old who’d caught rhinovirus and ended up in the ICU.

    Also on the list of smoochable threats is herpes simplex 1, the virus responsible for cold sores. “That’s the one I worry about the most,” says Annabelle de St. Maurice, a pediatric-infectious-disease specialist at UCLA and the mother of a 1-year-old daughter. Most American adults harbor chronic HSV-1 infections in their mouth with no symptoms at all, save for maybe the occasional lesion. But the super-transmissible virus can spread throughout the body of an infant, triggering high fevers and seizures bad enough to require a visit to the hospital. For the first few weeks of a baby’s life, anyone with an active cold sore—blood relative, presidential candidate, or both—would do well to keep away. (Even a history of cold sores might warrant extra caution.)

    The lip-restraining guidance is most pertinent to people outside an infant’s household, experts told me, which can include extended family. Ideally, even grandparents “should not be kissing on the baby for at least the first few months,” Tan told me. Within a home, siblings attending day care and school—where it’s easy to pick up germs—might also want to sheathe their smackeroos at first. Years ago, Cameron’s own son had to be admitted to the hospital with RSV when he was six weeks old after catching the virus from his 4-year-old sister. Lakshmi Ganapathi, a pediatric-infectious-disease specialist at Boston Children’s Hospital, told me that she didn’t kiss her own two sons on the face before they hit the six-week mark—though experts told me that they don’t expect most parents to get this puritanical about puckering up.

    Read: The worst pediatric-care crisis in decades

    Baby-kissing—especially outside families and tight-knit social circles—isn’t a universal impulse: A few of my friends were rather shocked to hear that such a PSA was even necessary. But people’s threshold for instigating a loving lunge is far lower when it comes to babies than to older kids or adults. One colleague told me that strangers have reached into his daughter’s stroller to stroke her hair; another mentioned that randos have swooped in to tickle his son’s feet. When de St. Maurice takes strolls around her neighborhood with her daughter, she’s surprised by how often casual acquaintances will try to dive-bomb her baby with pursed lips.

    Then again, there is perhaps no lure more powerful than a tiny human. Babies snare us visually, with their wide eyes, round cheeks, and button noses; their scent wafts toward us like the heady perfume of a fresh cream scone. (One colleague with kids told me that inhaling that particular odor was, for him, “like huffing glue.”) Among primates, human infants are born especially vulnerable, in desperate need of help, and so we go into overdrive providing it, even to others’ babies, who—at least in our social species—might benefit from communal care. “It’s programmed into us,” Oriana Aragón, a social psychologist at the University of Cincinnati, told me. “I’m able to get really strong reactions out of people with just a photograph.” Even the urge to plant a wet one on someone else’s baby may have adaptive roots in kiss feeding, the practice of delivering pre-chewed meals to an infant lip to lip, says Shelly Volsche, an anthropologist at Boise State University. Kiss-feeding isn’t very popular in the United States today, but it’s still practiced by many groups around the globe.

    Read: Pregnancy is a war; birth is a cease-fire

    But as important as these acts are for babies, they can also be at odds with an infant’s health when a bunch of respiratory viruses are swirling about. Those costs aren’t always top of mind when a stranger locks eyes with a tiny human across the way, and it can be “a really awkward conversation,” de St. Maurice told me, to deter someone who just wants to shower affection on your child. Cameron recommends being frank: “I’m just trying to protect my baby.” Physical deterrents can help, too. “Put them in the stroller, put the canopy up, buckle the baby in, make it as difficult as possible,” she said. That’s a lot of barriers for even the most dedicated baby kissers to surmount. De St. Maurice also likes to point out that her little infant, as adorable as she is, “could also potentially transmit something to you.” Plus, by the time they’re six months old, babies may be experiencing their first whiffs of stranger danger and react negatively to unfamiliar hands and mouths. “That’s not particularly good for the baby, and the stranger wouldn’t get anything out of it either,” says Ann Bigelow, a developmental psychologist at St. Francis Xavier University, in Canada.

    Again, this advice isn’t meant to starve infants of tactile stimulation. Kids need to be exposed to the outside world and all of its good-germiness. More than that, they need a lot of physical touch. “The skin is our largest sense organ,” Bigelow told me. Skin-to-skin contact stimulates the release of oxytocin, and cements the bond between a caregiver and an infant. Kissing doesn’t have to be the means for giving that affection, though it certainly can be. “Heck, when I’m a grandparent, I’m going to be kissing my grandchild,” Cameron told me. “Just try and stop me.”

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    Katherine J. Wu

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  • China’s COVID Wave Is Coming

    China’s COVID Wave Is Coming

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    In China, a dam seems on the verge of breaking. Following a wave of protests, the government has begun to relax some of its most stringent zero-COVID protocols, and regional authorities have trimmed back a slew of requirements for mass testing, quarantine, and isolation. The rollbacks are coming as a relief for the many Chinese residents who have been clamoring for change. But they’re also swiftly tilting the nation toward a future that’s felt inevitable for nearly three years: a flood of infections—accompanied, perhaps, by an uncharted morass of disease and death. A rise in new cases has already begun to manifest in urban centers such as Chongqing, Beijing, and Guangzhou. Now experts are waiting to see just how serious China’s outbreak will be, and whether the country can cleanly extricate itself from the epidemic ahead.

    For now, the forecast “is full of ifs and buts and maybes,” says Salim Abdool Karim, an epidemiologist at the Centre for the AIDS Programme of Research in South Africa. Perhaps the worst can be averted if the government does more to vaccinate the vulnerable and prep hospitals for a protracted influx of COVID patients; and if the community at large reinvests in a subset of mitigation measures as cases rise. “There is still the possibility that they may muddle through it without a mass die-off,” says Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations. “But even the most smooth and orderly transition,” he told me, “will not prevent a surge of cases.”

    China represents, in many ways, SARS-CoV-2’s final frontier. With its under-vaccinated residents and sparse infection history, the nation harbors “a more susceptible population than really any other large population I can think of,” says Sarah Cobey, an computational epidemiologist at the University of Chicago. Soon, SARS-CoV-2 will infiltrate that group of hosts so thoroughly that it will be nearly impossible to purge again. “Eventually, just like everyone else on Earth, everyone in China should expect to be infected,” says Michael Worobey, an evolutionary virologist at the University of Arizona.

    Read: How many COVID deaths will Chinese protesters accept?

    Whatever happens, though, China’s coming wave won’t recapitulate the one that swept most of the world in early 2020. Though it’s hard to say which versions of the virus are circulating in the country, a smattering of reports confirm the likeliest scenario: BF.7 and other Omicron subvariants predominate. Several of these versions of the virus seem to be a bit less likely than their predecessors to trigger severe disease. That, combined with the relatively high proportion of residents—roughly 95 percent—who have received at least one dose of a COVID vaccine, might keep many people from falling dangerously ill. The latest figures out of China’s CDC marked some 90 percent of the country’s cases as asymptomatic. “That’s an enormous fraction” compared with what’s been documented elsewhere, says Ben Cowling, an epidemiologist at the University of Hong Kong.

    That percentage, however, is undoubtedly increased by the country’s ultra-rigorous testing practices, which have been catching silent cases that other places might miss. All of Omicron’s iterations also remain capable of triggering severe disease and long COVID. And there are still plenty of worrying omens that climbing cases could reach a horrific peak, sit on a prolonged plateau, or both.

    One of China’s biggest weak spots is its immunity, or lack thereof. Although more than 90 percent of all people in the country have received at least two COVID shots, those over the age of 80 were not prioritized in the country’s initial rollout, and their rate of dual-dose coverage hovers around just 66 percent. An even paltrier fraction of older people have received a third dose, which the World Health Organization recommends for better protection. Chinese officials have vowed to buoy those numbers in the weeks ahead. But vaccination sites have been tougher to access than testing sites, and with few freedoms offered to the immunized, “the incentive structure is not built,” says Xi Chen, a global-health expert at Yale. Some residents are also distrustful of COVID vaccines. Even some health-care workers are wary of delivering the shots, Chen told me, because they’re fearful of liability for side effects.

    Regardless of the progress China makes in plugging the holes in its immunity shield, COVID vaccines won’t prevent all infections. China’s shots, most of which are based on chemically inactivated particles of the 2020 version of SARS-CoV-2, seem to be less effective and less durable than mRNA recipes, especially against Omicron variants. And many of China’s residents received their third doses many months ago. That means even people who are currently counted as “boosted” aren’t as protected as they could be.

    All of this and more could position China to be worse off than other places—among them, Australia, New Zealand, and Singapore—that have navigated out of a zero-COVID state, says Caitlin Rivers, a senior scholar at the Johns Hopkins Center for Health Security. Australia, for instance, didn’t soften its mitigations until it had achieved high levels of vaccine coverage among older adults, Rivers told me. China has also clung to its zero-COVID philosophy far longer than any other nation, leaving itself to contend with variants that are better at spreading than those that came before. Other countries charted their own path out of their restrictions; China is being forced into an unplanned exit.

    What Hong Kong endured earlier this year may hint at what’s ahead. “They had a really, really bad wave,” Kayoko Shioda, an epidemiologist at Emory University, told me—far dwarfing the four that the city had battled previously. Researchers have estimated that nearly half the city’s population—more than 3 million people—ended up catching the virus. More than 9,000 residents died. And Hong Kong was, in some respects, in a better place to ease its restrictions than the mainland is. This past winter and spring, the city’s main adversary was BA.2, a less vaccine-evasive Omicron subvariant than the ones circulating now; officials had Pfizer’s mRNA-based shot on hand, and quickly began offering fourth doses. Hong Kong also has more ICU beds per capita. Map a new Omicron outbreak onto mainland China, and the prognosis is poor: A recent modeling paper estimated that the country could experience up to 1.55 million deaths in the span of just a few months. (Other analyses offer less pessimistic estimates.)

    Lackluster vaccination isn’t China’s only issue. The country has accumulated almost no infection-induced immunity that might otherwise have updated people’s bodies on recent coronavirus strains. The country’s health-care system is also ill-equipped to handle a surge in demand: For every 100,000 Chinese residents, just 3.6 ICU beds exist, concentrated in wealthier cities; in an out-of-control-infection scenario, even a variant with a relatively low severe-disease risk would prove disastrous, Chen told me. Nor does the system have the slack to accommodate a rush of patients. China’s culture of care seeking is such that “even when you have minor illness, you seek help in urban health centers,” Huang told me, and not enough efforts have been made to bolster triage protocols. More health-care workers may become infected; patients may be more likely to slip through the cracks. Next month’s Lunar New Year celebration, too, could spark further spread. And as the weather cools and restrictions relax, other respiratory viruses, such as RSV and flu, could drive epidemics of their own.

    That said, spikes of illness are unlikely to peak across China at the same time, which could offer some relief. The country’s coming surge “could be explosive,” Cobey told me, “or it could be more of a slow burn.” Already, the country is displaying a patchwork of waxing and waning regulations across jurisdictions, as some cities tighten their restrictions to combat the virus while others loosen up. Experts told me that more measures may return as cases ratchet up—and unlike people in many other countries, the Chinese may be more eager to readopt them to quash a ballooning outbreak.

    Read: China’s zero tolerance for Xi’s COVID restrictions

    A major COVID outbreak in China would also have unpredictable effects on the virus. The world’s most populous country includes a large number of immunocompromised people, who can harbor the virus for months—chronic infections that are thought to have produced variants of concern before. The world may be about to witness “a billion or more opportunities for the virus to evolve,” Cowling told me. In the coming months, the coronavirus could also exploit the Chinese’s close interactions with farmed animals, such as raccoon dogs and mink (both of which can be infected by SARS-CoV-2), and become enmeshed in local fauna. “We’ve certainly seen animal reservoirs becoming established in other parts of the world,” Worobey told me. “We should expect the same thing there.”

    Then again, the risk of new variants spinning out of a Chinese outbreak may be a bit less than it seems, Abdool Karim and other experts told me. China has stuck with zero COVID so long that its population has, by and large, never encountered Omicron subvariants; people’s immune systems remain trained almost exclusively on the original version of the coronavirus, raising only defenses that currently circulating strains can easily get around. It’s possible that “there will be less pressure for the virus to evolve to evade immunity further,” says Emma Hodcroft, a molecular epidemiologist at the University of Bern; and any new versions of the virus that do emerge might not fare particularly well outside of China. In other words, the virus could end up trapped in the very country that tried to keep it out the longest. Still, with so many people susceptible, Cobey told me, there are zero guarantees.

    Either way, viral evolution will plod on—and as it does, the rest of the world may struggle to track it in real time, especially as the cadence of Chinese testing ebbs. Cowling worries that China will have trouble monitoring the number of cases in the country, much less which subvariants are causing them. “There’s going to be a challenge in having situational awareness,” he told me. Shioda, too, worries that China will remain tight-lipped about the scale of the outbreak, a pattern that could have serious implications for residents as well.

    Even without a spike in severe disease, a wide-ranging outbreak is likely to put immense strain on China—which may weigh heavily on its economy and residents for years to come. After the SARS outbreak that began in 2002, rates of burnout and post-traumatic stress among health-care workers in affected countries swelled. Chinese citizens have not experienced an epidemic of this scale in recent memory, Chen told me. “A lot of people think it is over, that they can go back to their normal lives.” But once SARS-CoV-2 embeds itself in the country, it won’t be apt to leave. There will not be any going back to normal, not after this.

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    Katherine J. Wu

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  • ‘It Just Seems Like My Patients Are Sicker’

    ‘It Just Seems Like My Patients Are Sicker’

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    The most haunting memory of the pandemic for Laura, a doctor who practices internal medicine in New York, is a patient who never got COVID at all. A middle-aged man diagnosed with Stage 3 colon cancer in 2019, he underwent surgery and a round of successful chemotherapy and was due for regular checkups to make sure the tumor wasn’t growing. Then the pandemic hit, and he decided that going to the hospital wasn’t worth the risk of getting COVID. So he put it off … and put it off. “The next time I saw him, in early 2022, he required hospice care,” Laura told me. He died shortly after. With proper care, Laura said, “he could have stayed alive indefinitely.” (The Atlantic agreed to withhold Laura’s last name, because she isn’t authorized to speak publicly about her patients.)

    Early in the pandemic, when much of the country was in lockdown, forgoing nonemergency health care as Laura’s patient did seemed like the right thing to do. But the health-care delays didn’t just end when America began to reopen in the summer of 2020. Patients were putting off health care through the end of the first pandemic year, when vaccines weren’t yet widely available. And they were still doing so well into 2021, at which point much of the country seemed to be moving on from COVID.

    By this point, the coronavirus has killed more than 1 million Americans and debilitated many more. One estimate shows that life expectancy in the U.S. fell 2.41 years from 2019 to 2021. But the delays in health care over the past two and a half years have allowed ailments to unduly worsen, wearing down people with non-COVID medical problems too. “It just seems like my patients are sicker,” Laura said. Compared with before the pandemic, she is seeing more people further along with AIDS, more people with irreversible heart failure, and more people with end-stage kidney failure. Mental-health issues are more severe, and her patients struggling with addiction have been more likely to relapse.

    Even as Americans are treating the pandemic like an afterthought, a disturbing possibility remains: COVID aside, is the country simply going to be in worse health than before the pandemic? According to health-care workers, administrations, and researchers I talked with from across the country, patients are still dealing with a suite of problems from delaying care during the pandemic, problems that in some cases they will be facing for the rest of their lives. The scope of this damage isn’t yet clear—and likely won’t come into focus for several years—but there are troubling signs of a looming chronic health crisis the country has yet to reckon with. At some point, the emergency phase of COVID will end, but the physical toll of the pandemic may linger in the bodies of Americans for decades to come.

    During those bleak pre-vaccine dark ages, going to the doctor could feel like a disaster in waiting. Many of the country’s hospitals were overwhelmed with COVID patients, and outpatient clinics had closed. As a result, in every week through July 2020, roughly 45 percent of American adults said that over the preceding month, they either put off medical care or didn’t get it at all because of the pandemic. Once they did come in, they were sicker—a trend observed for all sorts of ailments, including childhood diabetes, appendicitis, and cancer. A recent study analyzed the 8.4 million non-COVID Medicare hospitalizations from April 2020 to September 2021 and found not only that hospital admissions plummeted, but also that those admitted to hospitals were up to 20 percent more likely to die—an astonishing effect that lasted through the length of the study.

    Partly, that result came about because only those who were sicker made it to the hospital, James Goodwin, one of the study’s authors and a professor at the University of Texas Medical Branch, in Galveston, told me. It was also partly because overwhelmed hospitals were giving worse care. But Goodwin estimates that “more than half the cause was people delaying medical care early in their illness and therefore being more likely to die. Instead of coming in with a urinary tract infection, they’re already getting septic. I mean, people were having heart attacks and not showing up at the hospital.”

    Read: America is sliding into the long pandemic defeat

    For some conditions, skipping a checkup or two may not matter all that much in the long run. But for other conditions, every doctor’s visit can count. Take the tens of millions of Americans with vascular issues in their feet and legs due to diabetes or peripheral artery disease. Their problems might lead to, say, ulcers on the foot that can be treated with regular medical care, but delays of even a few months can increase the risk of amputation. When patients came in later in 2020, it was sometimes too late to save the limb. An Ohio trauma center found that the odds of undergoing a diabetes-related amputation in 2020 were almost 11 times higher once the pandemic hit versus earlier in the year.

    Although only a small percentage of Americans lost a limb, the lack of care early in the pandemic helped fuel a dangerous spike in substance-abuse disorders. In a matter of weeks or months, people’s support systems collapsed, and for some, years of work overcoming an addiction unraveled. “My patients took a huge step back, probably more than many of us realize,” Aarti Patel, a physician assistant at a Lower Manhattan community hospital, told me. One of her patients, a man in his late 50s who was five years sober, started drinking again during the pandemic and eventually landed in the hospital for withdrawal. Patients like this man, she said, “would have really difficult, long hospital stays, because they were at really high risk of DTs, alcohol seizures. Some of them even had to go to the ICU because [the withdrawal] was so severe.”

    Later in the year, when doctors’ offices were up and running, “a lot of patients expressed that they didn’t want to go back for care right away,” says Kim Muellers, a graduate student at Pace University who is studying the effects of COVID on medical care in New York City, North Carolina, and Florida. Indeed, through the spring of 2021, the top reason Medicare recipients failed to seek care was they didn’t want to be at a medical facility. Other people were avoiding the doctor because they’d lost their job and health insurance and couldn’t afford the bills.

    The problem, doctors told me, is that all of those missed appointments start to add up. Patients with high blood pressure or blood sugar, for example, may now be less likely to have their conditions under control—which after enough time can lead to all sorts of other ailments. Losing a limb can pose challenges for patients that will last for the rest of their lives. Relapses can put people at a higher risk for lifelong medical complications. Cancer screenings plummeted, and even a few weeks without treatment can increase the chance of dying from the disease. In other words, even short-term delays can cause long-term havoc.

    Read: How long can the coronavirus keep reinfecting us?

    To make matters worse, the health-care delays fueling a sicker America may not be totally over yet, either. After so many backups, some health-care systems, hobbled by workforce shortages, are scrambling to address the pent-up demand for care that patients can simply no longer put off, according to administrators and doctors from several major health systems, including Cleveland Clinic, the Veterans Health Administration, and Mayo Clinic. Disruptions in the global supply chain are forcing doctors to ration basic supplies, adding to backlogs. Amy Oxentenko, a gastroenterologist at Mayo Clinic in Arizona who helps oversee clinical practice across the entire Mayo system, says that “all of these things are just adding up to a continued delay, and I think we’ll see impacts for years to come.”

    It’s still early, and not everything that providers told me is necessarily showing up in the data. Oddly enough, the CDC’s National Health Interview Survey found that most Americans were able to see a doctor at least once during the first year of the pandemic. And the same survey has not revealed any uptick in most health conditions, including asthma episodes, high blood pressure, and chronic pain—which might be expected if America were getting sicker.

    It’s even conceivable that the disturbing observations of clinicians are a statistical illusion. If for whatever reason only sicker people are now being seen by—or able to access—a doctor, then it can be true both that providers are seeing more seriously ill patients in medical facilities and that the total number of seriously ill people in the community is staying the same. The scope of the damage just isn’t yet clear: Maybe a smaller number of people will be worse off because of delayed cancer care or substance-abuse relapses, or maybe far more people—more than tens of million of Americans—will be dealing with exacerbated issues for the rest of their lives.

    None of this accounts for what COVID itself is doing to Americans, of course. The health-care system is only beginning to grapple with the ways in which a past bout with COVID is a long-term risk for overall health, or the extent to which long COVID can complicate other conditions. The pandemic may feel “over” for lots of Americans, but many who made it through the gantlet of the past two-plus years may end up living sicker, and dying sooner.

    This disturbing prospect is not only poised to further devastate communities; it’s also bad news for health-care workers already exhausted by COVID. Laura, the Manhattan internist who treated the colon-cancer patient, told me it’s disheartening to see so many people showing up at irreversible points in their disease. “As doctors,” she said, “our overall batting average is going down.” Aarti Patel, the physician assistant, put it in blunter terms: “Burnout is probably too simple a term. We’re in severe moral distress.”

    Nothing about this grim fate was inevitable. Laura told me that “going to the doctor mid-pandemic may have posed a small risk in terms of COVID, but not going was risky in terms of letting disease go unchecked. And in retrospect it seems that many people didn’t quite get that.” But there didn’t have to be such a stark trade-off between fighting a pandemic and maintaining health care for other medical conditions.

    Some hospitals—at least the better-resourced ones—figured out how to avoid the worst kind of delays. Mayo Clinic, for example, is one of a number of systems with a sophisticated triage algorithm that prioritizes patients needing acute care. In the spring of 2021, Cleveland Clinic launched a massive outreach blitz to schedule some 86,000 appointments, according to Lisa Yerian, the chief improvement officer. And the Veterans Health Administration provided iPads to thousands of veterans who lacked other means of accessing the internet in the spring of 2020, ensuring a more seamless transition to virtual care, Joe Francis, who directs health-care analytics, told me. Thanks in part to these efforts, Francis said, high-risk patients at the VHA were being seen at pre-pandemic levels a mere six months into the pandemic.

    These health-care systems also suggest a path forward. America may still be able to stave off the worst of the collateral damage by reaching the patients who have fallen through the cracks—and already the data suggest that these patients tend to be disproportionately Black, Hispanic, and low-income. Tragically, it’s too late for some Americans: People who died of cancer can’t come back to life; amputated limbs can’t regrow. Others still have plenty of time. Hypertension that’s currently uncontrolled can be tamped down before causing an early heart attack; drinking that’s gotten out of hand can be corralled before it leads to liver failure in a decade; undetected tumors can be spotted in time for treatment. An uptick in premature death and disability, summed over millions of Americans, could strain the health-care system for years. But it’s still possible to prevent an acute public-health crisis from seeding an even bigger chronic one.

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    Tim Requarth

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