Counting Covid-19 Cases Doesn’t Capture the Pandemic’s Impact

At some point, hopefully soon, infections from the latest variant to emerge during the Covid-19 pandemic will subside, and it will be easy for many Americans to believe that they made it through another surge unscathed. But in fact, we don’t have a simple way of measuring the long-term impact of Omicron — or the pandemic as a whole — on everyone’s health or what kinds of consequences it will have on our health care system. “Even from the early days of the pandemic,” says Caleb Alexander, a professor of epidemiology and medicine at the Johns Hopkins Bloomberg School of Public Health, “it’s been clear that there are going to be any number of large collateral effects.” What’s less clear at this point is how to even define those effects, let alone quantify them.

There’s virtually no aspect of our lives that the pandemic hasn’t changed. And the limited data sets available suggest that its impact on other health conditions will also be vast. In December, the National Center for Health Statistics released its final analysis of mortality data for 2020. Heart disease and cancer remained the two leading causes of death; Covid-19 became the third. The age-​adjusted death rate for the U.S. population increased nearly 17 percent, the greatest jump in more than 75 years. Covid deaths were not the only factor that contributed to that rise, though. The death rates from cardiovascular disease — that is, strokes and heart disease — increased by 9 percentage points and from Alzheimer’s by 8.7 percentage points. Deaths from diabetes increased nearly 15 percentage points.

The death certificates on which those figures are based include limited information about what other factors may have contributed to the official cause. Some of them may have been misclassified, with a Covid infection at least partly responsible, according to Elizabeth Arias, a researcher at the National Center for Health Statistics and one of the report’s authors. Diabetes, cardiovascular disease and Alzheimer’s all put people at greater risk from Covid, which can in turn exacerbate those conditions. “Or these were deaths that resulted from people who did not attend their doctor’s visits or go to the hospital because of Covid,” Arias says. “At this point, all we can do is speculate.”

Anecdotal reports, modeling and studies of smaller groups all suggest that many of those deaths were very likely preventable — a result of changes in lifestyle and in access to health care and medication caused by the pandemic. The Alzheimer’s Association posits that social isolation, difficulty managing other health conditions and the “disruption of steady routines and close care provided by family members” may have contributed to the rise in Alzheimer’s deaths. The C.D.C. calculates that 64,000 more people than expected died from Alzheimer’s since Feb. 1, 2020. Controlling diabetes and cardiovascular disease each include eating a healthy diet, exercising, reducing stress and adhering to a regular schedule of medications — all of which were made difficult by the pandemic, particularly for those whose access to health care was already limited. Over the past two years, diabetes has killed 35,000 more people than the average rate would have predicted, and circulatory diseases have killed 136,000 more.

“It confirms what many of us have been seeing: I don’t think people are getting as much routine care for chronic diseases during the pandemic as they did before,” says Elizabeth Seaquist, director of the division of diabetes, endocrinology and metabolism at the University of Minnesota Medical School. She notes that many patients at various points have been reluctant to leave home to seek treatment for fear of infection. “I have patients who I haven’t seen in a long time, and when I see them, it’s concerning.”

Often, though, the changes that physicians are seeing and that patients are experiencing are difficult to quantify unless they lead to an outcome that government agencies can track. To see how the pandemic has affected the care that people get for opioid-use disorder, for instance, or that adolescents get for depression, researchers will first have to decide where to look, Alexander says. “The questions are too broad and the implications of the pandemic too diverse for there to be a single information repository that we can rely on to understand what’s going on.”

Credit…Illustration by Hanna Barczyk

Hospitalization figures, one of the few health care system indicators available in real time, have shown an association between Covid surges and other fatalities. In November, a study conducted by the Covid task force at the Cybersecurity and Infrastructure Security Agency examined hospital data from July 4, 2020, through July 10, 2021, a period that included the rise of the Delta variant. It found that if the use of I.C.U. beds nationwide reached 75 percent capacity, 12,000 additional deaths from all causes could be expected to occur in the U.S. over the following two weeks; at 100 percent capacity, the number would rise to 80,000 deaths.

But other unnecessary deaths are only now being set in motion. When hospitals fill up during Covid surges, for example, elective surgeries are postponed. Yet “elective” — a designation that applies to everything from cancer removal to joint replacement and accounts for about 90 percent of operations in the U.S. — doesn’t mean “optional.” “Elective cases are no less essential, but they can be scheduled,” says Patricia Turner, executive director of the American College of Surgeons, which published guidance early in the pandemic for how hospitals should triage patients. “Patients who delay their surgery may be worse by the time they get to the operating room.” If they have complications or don’t survive, however, that Covid-​related delay won’t be listed as their cause of death or disability.

The same is true for missed cancer screenings. The National Cancer Institute has not yet released statistics for 2020, but its director, Norman E. Sharpless, predicts that there will be a decline in reported cases. “Not because coronavirus prevented cancer,” he says, but “because less cancer was diagnosed. I don’t think that’s a good thing.” More than nine million people in the U.S. missed screenings for breast, colorectal and prostate cancers, a drop that occurred largely between March and May that year, according to a 2021 paper in JAMA Oncology that generated estimates based on the insurance records of 60 million people. Monthly screening rates were nearly back to normal by July 2020. But, Sharpless adds: “We don’t think we will ever be able to make up those missed number of screenings. Those cancers that would have been detected by screening will still be diagnosed but at a later stage when it’s harder to treat.”

The Coronavirus Pandemic: Key Things to Know

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Omicron in retreat. Though the U.S. is still facing overwhelmed hospitals and more than 2,000 deaths a day, encouraging signs are emerging as new cases start to fall nationally. The World Health Organization said the variant offered “plausible hope for stabilization.”

New York mask mandate. An appeals court judge granted a motion by the New York attorney general to temporarily block a lower-court ruling that had struck down the state’s mask mandate. The rule, which was renewed by Gov. Kathy Hochul in December and currently remains in effect, required masks or proof of vaccination at all indoor public places.

Around the world. The European Union recommended that residents traveling within the bloc who have been vaccinated or have recovered from the virus should not face additional restrictions like testing or quarantine. In China, officials reported a case within a bubble set up to insulate Olympic participants from the rest of the country.

Staying safe. Worried about spreading Covid? Keep yourself and others safe by following some basic guidance on when to test, which mask to pick and how to use at-home virus tests. Here is what to do if you test positive for the coronavirus.

In June 2020, Sharpless published an editorial in Science predicting a 1 percent increase in deaths from colon and breast cancer alone over the next decade as a result of missed screenings — an additional 10,000 fatalities. That prediction, though, which assumed “a moderate disruption” in care that ends after six months, is most likely a significant underestimate.

Delays in all sorts of preventive care will mean higher financial costs to patients and the system, says Tonette Krousel-Wood, president of the American College of Preventive Medicine. But they will also increase costs that we don’t have metrics for, like time lost and diminished quality of life. “When you have earlier detection and earlier treatment and earlier management, you have less unnecessary suffering and pain,” she adds.

Without a clear picture of the collateral damage the pandemic has caused, it will be hard to figure out what efforts to prioritize when the virus finally recedes. (That damage includes an untold number of cases of long Covid, for which doctors are struggling to find treatments.) “Sure, mortality counts, but so, too, do the number of heart attacks or strokes or cases of bacterial pneumonia,” Alexander says. “Colonoscopies and mammograms and concern about surgical delays — those are just scratching the surface. They may be easiest to observe and count, but the pandemic has undoubtedly affected the health care of tens of millions of Americans in fundamental ways that I think are only beginning to be able to be understood.”

Kim Tingley is a contributing writer for the magazine.

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