April 2020, Volume XXXIV, No 01

Epidemiology

Life in a global pandemic

Helping patients cope

n Feb. 11, the World Health Organization (WHO) announced the name of COVID-19, the novel coronavirus that had spread terror throughout Asia and Europe, and by then had already claimed the lives of thousands. Efforts to slow the spread to the United States was a topic of alarm and uncertainty. We knew little about COVID-19, which seemed shrouded in mystery, so far untreatable, and highly discriminatory to the elderly and those with weakened immune systems.

President Trump declared a national state of emergency on March 13 and the stock market immediately plummeted, school was cancelled, businesses closed indefinitely, and the summer Olympics postponed. While many of us have lived through times of natural disasters, wars, recessions, and other outbreaks, no other event in recent history has impacted our daily lives like COVID-19. This pandemic has created an unprecedented existential threat to our daily lives that has created mass anxiety, fueled by daily uncertainty amplified by the speed with which new information and epidemiological data is being reported. There are no vaccines or treatments, there is no herd immunity, and your immune system has never seen this virus before. In addition, testing capabilities are lacking, and even the accuracy of results has been scrutinized.

The state’s health care preparedness

Minnesota’s health care infrastructure is well-established and well-respected. Preventative and specialty services are accessible and robust, cooperation between payers and providers is high, and our hospitals are recognized among some of the best in the nation. The strong work ethic and patient-centered culture among our professionals is enviable, and has put the patient experience and outcomes on the forefront. By any standards, Minnesota’s hospitals and health care workforce are as well prepared as any to face these threats head-on.

However, when the threat of novel coronavirus manifested as a community spread killer, our system that valued high quality and integrity was instantly shaken. In retrospect, seeing empty store shelves where toilet paper and soap had been displayed was the canary in the coal mine warning of unprecedented problems ahead. Doctors and nurses never imagined fighting infectious diseases while wondering if they would have enough gloves, masks, and gowns. The thought of needing a thousand extra ventilators stored in reserve was both unthinkable and certainly cost-prohibitive. Information from the federal government on our lack of reliable testing almost seemed farcical. Many health care providers are now anxious or even fearful of going to work with a lack of personal protective equipment (PPE) and necessary medical equipment to save lives.

COVID-19 dominates most [mental health] treatment sessions.

While the camaraderie among Minnesota’s health care leaders is extraordinary, the unprecedented level of coordination required to manage emergency supplies and beds had not been rehearsed. And finally, the most crippling blow to our hospitals, leading to an ultimate paradox, was the necessary executive order to postpone all elective surgeries and non-essential procedures. The intention was to preserve our valuable supply of personal protective equipment and avoid exposing otherwise healthy patients to possibly infected carriers. The devastating result was the hardest financial hit Minnesota health care has ever experienced. While operating normally on a meager 1.7% margin, eliminating elective care procedures immediately resulted in a downturn in health care revenue of nearly 50% across the state, or an average loss of 31 million dollars per day. Many outpatient practices, including primary care and specialty care, have closed and furloughed significant portions of their workforce. Doctors and nurses have had their hours decreased during a time that our communities may need them the most. Rural hospitals are being hit the hardest, reporting nearly a 70% decrease in overall revenues since the executive order. We are preparing for a surge in COVID-19 patients that will overwhelm our hospitals and require creativity and adaptability that this workforce has never seen on such a massive scale.

Our deservedly proud health care system is now battling a mysterious invisible killer, fragmented between a hundred circumstantially under-equipped hospitals and alternative care sites with half of their usual funding, and a workforce that is skeptical—but nonetheless, dedicated, selfless, and impassioned. In Bill Gates’ 2015 TED Talk about pandemics, he clearly stated that our health care systems have the people, science, and technology to defeat pandemics. What we lack is the large-scale coordination, interstate cooperation, and disaster rehearsals. Governors are unwittingly bidding against one another for basic supplies and support from the private sector, only to have the federal government buying stockpiles from underneath them. Minnesota has been recognized as a national leader in “flattening the curve,” citing our strong community bonds and social consciousness as notable factors, yet we are not  infallible and nonetheless are facing the mortal effects of infection, economic devastation, societal disruption, and degradation of our mental health.

To punctuate the seriousness of the situation, the Centers for Medicaid and Medicare Services (CMS) reacted swiftly in early March by waiving bits and pieces of some of our most formidable federal laws governing US health care, such as EMTALA, HIPAA, Stark Law, and more. So far, a total of more than 100 waivers have been issued to increase access to care and to break down barriers during this crisis. These laws had carried steadfast enforcement and threat of serious penalties. Suddenly, the walls came down and the federal government made it clear—care for patients first, document later.

The impact on mental health

Each day nearly 20% of individuals struggle with symptoms of a mental illness, which have only been amplified during this pandemic. According to a poll conducted by the American Psychiatric Association in late March, “more than one-third of Americans (36%) say coronavirus is having a serious impact on their mental health and most (59%) feel coronavirus is having a serious impact on their day-to-day lives. Most adults are concerned that the coronavirus will have a serious negative impact on their finances (57%) and almost half are worried about running out of food, medicine, and/or supplies. Two-thirds of Americans (68%) fear that the coronavirus will have a long-lasting impact on the economy.” Mental health experts are keenly tuned in to the impact of trauma and vicarious trauma on families and societies.

Mental health needs are on the rise. Paradoxically, so are the barriers to accessing and providing care. Most healthy individuals receive emotional support from their peer groups and social circles, which have now been intentionally distanced and, at best, moved online. Mental health clinicians across the state are reporting that the topic of COVID-19 dominates most treatment sessions. Many patients are fearful of leaving the house, or are cancelling sessions for fear of job loss or financial strains. PrairieCare Medical Group saw a decrease of nearly 50% in outpatient sessions within days of the state’s declaration of a state of national emergency.

While PrairieCare previously had provided about 5% of visits using telehealth, that number is now closer to 80% of visits done by telehealth, including group therapies. The waivers issued by CMS have greatly relaxed the rules for providing care using telehealth, which has benefited hundreds of individuals. Services can now be provided across state lines, physicians are able to prescribe new medications via telehealth, and almost any televideo platform can be used regardless of encryption level (previously a costly barrier for mental health clinicians). While not all psychiatric services can be done using telehealth, this method of care delivery will help thousands remain connected to their supportive services through this crisis.

When patients experience a psychiatric crisis—such as panic attacks, a suicide attempt, drug overdose, or others—most often they end up in a hospital or emergency room. It is going to be critical that mental health services remain fully intact and more accessible than ever so patients experiencing these crises can avoid hospital or emergency room visits, especially during the anticipated COVID-19 surge.

While some of the larger societal disruptions have an obvious impact on mental health, other effects can be more subtle but equally impactful. Sleep experts and psychiatrists carefully monitor patients’ circadian rhythms—the physical, mental, and behavioral changes that follow one’s usual daily cycle or routine. When even minimally disrupted, it can have a drastic impact on the quality of our restorative sleep, health, and well-being. As many of us have adapted our daily routines to accommodate such things as working from home, helping kids with distance learning, having groceries delivered, and cancelling weekly social events, our rhythms are unwittingly impacted. This can lead to poor sleep, headaches, dietary changes, weakened immune system functioning, and simply irritability. The compounding effect of these disruptions to our daily lives can manifest as noticeable stress, and over time, and without proper intervention or rationalization, will lead to mental illness. It is the secondary and tertiary impact of the pandemic, and the impact of our societal response that will be difficult to measure in the long term.

The real threat and the existential threat

Our daily lives have been disrupted by numerous events in the last several weeks, each one in itself enough to rattle an average resilient adult. It started with the recognition of the actual threat of COVID-19 in the United States that led to the state of emergency. Our global economy immediately plummeted in what is sure to be an enduring bear market. Then our means of daily entertainment—concerts, sports, socialization, and cultural events—were cancelled. We started talking about “social distancing” (a misnomer for what really means “physical distancing”) and slowing the spread. Soon after, schools closed with a government mandate to move to “distance learning,” a new concept for students, parents, and even teachers. Lastly, the Stay Home Minnesota executive order was announced, a formal effort to minimize transmission of the virus. The development of this pandemic’s storyline has created a societal situation today which few individuals and families prepared for, and our response and preparation has created the barriers to the resources that we need to persevere. The rationale for distancing from others is understood, but the order is not a temporary novelty, but an extreme measure to reduce chances for physical infections. This distancing has helped to slow the spread, but at a cost to our social welfare and emotional well-being.

While [we] previously had provided about 5% of visits using telehealth, that number is now closer to 80%.

We are hearing concerning stories about dysfunctional and fragmented family systems that are now forced to function together without support. The elderly are isolated from family and friends. Kids have lost their bearings on their normally comforting academic-social-developmental supports and structure. The future of many businesses and careers are unknown and on hold, indefinitely. There are currently five times more individuals applying for unemployment insurance than at the peak of the great recession. If that is not enough to wear down even the most resilient and optimistic of us, there is talk of the anticipated resurgence of this virus again next fall. The adaptations we’ve made to our normal lives has required us to find new strategies to cope with our new temporary normal: avoiding one terror only to face others.

At the time of this writing, most Minnesotans have been greatly impacted by the threat of COVID-19, but not yet by the virus itself. Current projections from leading doctors and scientists show that nearly half of our state’s population will be infected, reaching its peak sometime between May and July. A majority of those infected will have mild symptoms, or even none at all, while a small portion will become severely ill. Hospitals are working intensively to coordinate efforts to add over 1,000 beds, procure elusive PPE, and at least 800 more ventilators for this inevitable “surge.” The Minnesota Department of Health has run numerous models in an attempt to understand what to expect in the near future, and the confidence interval is alarmingly wide. It seems that with each new day, we discover problems with yesterdays’ information. As Dr. Tony Fauci stated on March 25th, “you don’t make the timeline, the virus makes the timeline.”

Life after a global pandemic

Many individuals and even businesses are going through the stages of grief, realizing that their past understanding of the world has changed. We have left our comfort zones and now need to face our fears, start to learn, and eventually enter the growth zone where we can rediscover ourselves, our businesses, and our lives. Whether moving through the stages of grief, or from the comfort zone to the growth zone, each person’s journey is unique. Some simple things that we can focus on to safely cope with these changes are:

  1. Pay attention to nutrition, sleep habits, and staying active. Oftentimes when we’re overwhelmed with stress, our healthy habits and routines quickly fall by the wayside. This will impact our circadian rhythm and have negative physiological effects before we even realize it.
  2. Stay positive and give others the benefit of the doubt. When we convey positivity, our bodies and environments respond accordingly. You will be able to let go of stress, and those around you will reciprocate. Helping others will give you a sense of agency when things seem out of control.
  3. Focus on the things that you can control. In moments of big uncertainty and overwhelm, stop wasting energy on things you can’t control. It is empowering to focus on things you can control, like organizing a bookshelf, baking, building furniture, or going on a run at your own pace.
  4. Practice radical self-acceptance. Accept everything about yourself, your current situation, and your life without question, blame, or pushback. You cannot fail at this—there is no roadmap, no precedent for this, and we are all truly doing the best we can in an impossible situation.

Our current focus on public health is altruistic and admirable, and our compassion will be our guiding light. We will eventually see the pandemic subside and more patients move to convalescent care. While treatment and vaccines are developed, there will be a long and enduring aftermath of continued medical and economic proportions. Our economy will recover, as it always has, and as individuals and as a society we will need to plan for healing. The executive orders that have created such disruption in efforts to slow the spread, will have their own fallout that will need to be addressed. Students who moved to distance learning will have missed important life events such as concerts, prom, athletic tryouts, state tournaments, and walking at commencement ceremonies. Patients who had to cancel or postpone elective procedures like mammograms, colonoscopies, skin cancer exams, and cataract surgeries are growing increasingly anxious. The procedures have simply been delayed, and otherwise preventable diseases will require inevitable treatments and cause mortality. The trauma and impact on mental health will be long lasting, and require specialized focus, care, and understanding. While measurements of those directly impacted by COVID-19 will be carefully tracked and reported, there will be an additional tenfold impact to our world that will go unmeasured and unreported.

A lesson from the past

In 1948, C.S. Lewis wrote an essay about the fear of living in the atomic age. He poignantly describes the threats that humankind has endured over time, such as plagues, wars, motor accidents, diseases, and more. He ends by sharing an uplifting (if not ironic) perspective that the “novelty of our situation” has never changed. The comparison of this historical writing to our current situation should neither downplay the seriousness of COVID-19, nor be applied directly to the present. Rather, it is a reminder that we should not succumb to panic or allow fear to dominate our minds or paralyze our hearts. It is more important than ever to live and laugh, and to enjoy our time with the ones that we love. Begin to understand or even accept that this pandemic will change our lives, and we will emerge stronger, more compassionate, and wiser.

Todd Archbold, LSW, MBA, is a licensed social worker and the chief executive officer at PrairieCare. 

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Todd Archbold, LSW, MBA, is a licensed social worker and the chief executive officer at PrairieCare.