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19 Truths We Must Face About Covid-19

Commentary: If we want schools and the economy to restart, we’ve got to accept some facts and deal with them

In reporting on the coronavirus since January, I’ve interviewed dozens of infectious-disease researchers, epidemiologists and other scientists and health experts, and this much is crystal clear: The terrible situation we’re in now was widely, loudly and frequently predicted since very early on. Many U.S. political leaders didn’t listen then. If they don’t listen now, it will just get worse. At least, that’s what the experts say. Here’s a review of lessons not learned, the foibles that got us here, and the sad fact about who must take responsibility to change the course of the growing pandemic.

1: We knew in early February that this already was or would soon be a global pandemic. And we knew then that the handful of U.S. cases were just a prelude…

“It’s very, very transmissible, and it almost certainly is going to be a pandemic.”
—Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Disease, February 2, 2020

“We are preparing as if this were the next pandemic.”
— Dr. Nancy Messonnier, director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention (CDC), said February 3, 2020

“It appears we are currently in the early stages of a mild pandemic.”
— Dr. Amesh Adalja, an infectious disease expert at the Center for Health Security at Johns Hopkins University, February 5, 2020

But from the beginning, the experts were ignored and the reality distorted…

“It’s an unforeseen problem.”
— President Donald Trump, March 6, 2020

“It’s something that nobody expected.”
— President Donald Trump, March 14, 2020

“Nobody could have predicted something like this.”
— President Donald Trump, March 30, 2020

2: We knew in early April, when New York City was in the midst of its crisis, that the disease would spread across the country. “Every state will experience their own curve and their own peak,” Mark Cameron, PhD, an immunologist and medical researcher in the School of Medicine at Case Western Reserve University in Ohio, said on April 4, joining a chorus of experts predicting same.

3: Three months later, after economically and socially brutal shutdowns, every measure of the Covid-19 pandemic is now going in the wrong direction nationwide: New cases are soaring, hospitalizations are rising, and deaths, which lag behind both of those metrics, are starting a long-predicted uptick.

4: Like few other threats to the health of American people and the economy, the response to the Covid-19 pandemic nationally and in several states is marked not by missteps but by outright refusal to listen to health experts and accept established science. From Feb. 10 through July 1, President Trump has predicted at least 19 times that the coronavirus would just go away, including claiming that “like a miracle, it will disappear.” The White House has silenced the CDC repeatedly and announced the U.S. will withdraw from the World Health Organization. Mind you, these are the two top health organizations in the world when it comes to pandemic response. This is, plain and simple, antiscience.

5: The lack of a national plan, of leadership from the top, and the White House’s outright dismissal of advice from health experts, are the main reasons that the United States leads the world in Covid-19 deaths, with 24% of the global total despite having just 4.2% of the world’s population. You don’t become №1 in deaths by doing more testing.

6: We can’t get the U.S. economy going or safely restart schools without healthy people — workers, teachers, parents and kids. We won’t have healthy people if we don’t stamp out the pandemic. “States that opened without controlling Covid had to close,” Dr. Tom Frieden, former head of the CDC, tweeted today. “It’s 100% predictable: schools that open with either extensive spread or without careful planning will have to close. It’s SO important that our kids get back to school. That’s why it’s so important we do so thoughtfully.” (Here’s what educators and scientists say is needed, and here’s why federal funding for school reopenings would make sense.)

7:Without serious effort, the pandemic could get much worse this fall. And it will be around for years to come, barring a vaccine, which so far is still at least months away and may never happen (successful vaccines are really hard to do). And no, natural herd immunity is not the answer, unless you just get a kick out of a million or more Americans dying.

8:The virus spreads incredibly easily, mostly through the air when people are within 6 feet of each other for some length of time, and especially indoors, and double especially if they’re not wearing masks. If that sounds like a rally, it is. We know this. We’ve known this for months. Any confusion over the value of masks has been cleared up for weeks.

9:The virus does not respect borders. It goes where people go. One state’s vigilance can be nullified by another state’s ambivalence, by one traveler, one ember.

10: The lockdowns were totally squandered, by opening back up too quickly and too widely and not requiring masks in public, and failing to limit large indoor gatherings.

11: The reopening of bars and indoor dining and large indoor gatherings should have been on a delay, allowed only after evidence showed that other reopenings were not causing outbreaks.

12: The party atmosphere that was fostered with total lifts of lockdowns helped wipe out all the gains, the flattening of the curve, and in fact caused a surge in infections among younger adults, which is partly behind the soaring number of cases now.

13: The more the virus spreads, the harder it will be to bring under control. Contact tracing, which can work early on in smaller outbreaks to get isolate people who might have been exposed, is near impossible to conduct when you have 60,000 new cases daily. Every new case, meanwhile, represents greater odds of additional infections.

14:There is no question that a serious, national strategy should have been, and still should be, put in place to fight this pandemic, just as nearly every other nation on the planet has done. There is no indication that will happen. But we should not throw up our hands.

15: Nothing should be more important for the White House and the nation’s governors right this moment than getting this pandemic under control. “This should be our number one national priority right now,” Caitlin Rivers, PhD, an epidemiologist at the Johns Hopkins Center for Health Security and assistant professor at the Johns Hopkins Bloomberg School of Public Health, said June 26. “We are headed in the wrong direction at top speed.”

16: The science and on-the-record evidence on all the above is solid. We are where the scientists predicted we would be, where all of them hoped we would not be. Anyone who says “Who knew this would happen?” was simply ignoring the evidence that was everywhere, in the media and in verbal and written briefings to top officials (and even a White House pandemic playbook created by the previous administration).

17: Yes, science is not perfect, and we can quibble about some details, the fumbles of communication, the uncertainties and evolving understanding of a novel virus, the late-coming advice on masks. But epidemiologists and other health experts have been remarkably prescient about the risk and the need for a national plan, and if we don’t listen to their advice now, they’ll tell you to expect 1 million or more American deaths before this is over.

18: People who don’t wear masks when around other people in public are either ignorant of the facts or self-centered and uncaring of their fellow humans. Some say shaming doesn’t work, but that’s not shaming, it’s just facts. We cover our genitals in public. We don’t smoke in restaurants anymore. We make our kids wear seatbelts. We stay at home when we have the flu. We get vaccines. We do things for the good of public health. Mask refusal is not about liberty. It’s about death.

19: Even without state or national leadership, there are three selfless and highly effective things we can all do toward the goal of making the nation, and the economy, healthier, and hopefully getting kids back to schools so parents can go back to work: Avoid large indoor crowds, keep distance, wear masks. The pandemic response should not have to be planned by the people, but it seems to have been left to us.

The Tragic Loss of Coronavirus Patients’ Final Words

It takes a special kind of inattention to human suffering to not notice how unfortunate it is that people have been left to face death alone

By Zeynep Tufekci

Of all the wrongdoings of this pandemic, the one that haunts me most is how people are left to die alone. Health-care workers have been heroic throughout all this, but they do not replace the loved ones whom the dying need to be with, and speak with, even if only one last time.

A hallmark of COVID-19 has been the speed with which some patients have crashed, going from feeling only a little sick to being unable to breathe, sometimes in the space of a few hours. Such a crash often necessitates intubation, a process that then renders one incapable of speaking. Many people on ventilators are also heavily sedated and unconscious, to keep them from pulling out the invasive tubes going down their throat. Thus, sometimes with little warning, all communication is lost, and more often than not, a patient is without family or loved ones when this happens.

Early in the pandemic, patients were left alone precisely because the crisis was so dire. Many hospitals outright banned visitors — often even to non-COVID-19 patients. They did not have enough protective gear for the health-care workers, let alone anyone else. Many COVID-19 patients were transported solo in ambulances, and family and friends were unable to join them at the hospital once they had arrived. Others were dropped off by loved ones who were then turned away. Patients sat in their rooms, waiting. If they experienced dyspnea, the acute shortness of breath known as “air hunger,” they crashed alone and terrified.

Sometimes, a nurse or doctor managed to connect the patient with their loved ones before the tube went in. But dyspnea is a medical emergency, after all, so in many cases there was simply no time for that last call, or anyone available to arrange it. As the disease progressed, families were left clustering around a phone as a hospital worker held up the device for a final goodbye on FaceTime. Often, the family could talk to their loved one, but not vice versa. That’s not enough. What the dying have to say must be heard.

The paramount importance of dying words has long been recognized across cultures. “When a bird is about to die, his song is sad,” Master Tseng, a Confucian leader, says in the more than two-millennia-old Analects of Confucius. “When a man is about to die, his words are true.” In Plato’s Phaedo, Socrates notes how swans sing most beautifully just as they are about to die. That concept of the swan song — one’s last, most beautiful expression — also comes up in Aesop’s fables and in Aeschylus’s Agamemnon, and was already a proverb by the third century b.c. In Shakespeare’s Richard II, a dying John of Gaunt, hoping the king will come to hear his last words, says:

O, but they say the tongues of dying men

Enforce attention like deep harmony.

Where words are scarce they are seldom spent in vain,

For they breathe truth that breathe their words in pain

Last words, or “dying declarations” as they are sometimes called, have long been recognized in jurisprudence as out of the ordinary, with known cases going back as early as 1202. That’s why statements uttered by people aware of their impending death can potentially be accepted in court without being subject to “hearsay” restrictions, which ordinarily exclude from evidence assertions made by those not in court to testify in person. In the Middle Ages, it was presumed that people alert to their immediate death would not dare lie, knowing they were about to meet their maker. Death was also seen as removing motives to lie: In a 1789 court case in England, which forms the basis of the modern hearsay exception, the court admitted a woman’s dying words — that her husband was her murderer — as evidence, noting that “when every hope of this world is gone: when every motive to falsehood is silenced,” then “the mind is induced by the most powerful considerations to speak the truth.”

The clarity that can come from those facing death is also integral to many modern traditions and philosophies, including the existentialist and psychotherapy schools of thought, which emphasize that death, meaning, loneliness, and freedom are core axes of our lives, and that making all these existential considerations explicit can be key to a good life. The Holocaust survivor Viktor Frankl talks about how these “primordial facts” of existence, including our mortality, help us realize and appreciate what truly brings meaning to our lives. The existential psychotherapist Irvin Yalom, who specializes in treating people with terminal illnesses, says that terminal cancer, as terrible as it is, gives patients clarity that they did not always have before: “What a pity I had to wait till now, till my body was riddled with cancer, to learn how to live,” a patient lamented to him. Yalom advocates listening to the dying and their wisdom even before we ourselves face our final stretch.

It’s also not just that the dying deserve to be heard or that their wisdom is valuable, but that the living need to have the chance to hear them — to let go on their own, mutual terms. That was something I learned the hard way, when my mother died unexpectedly in her 50s. There is no good way to lose a mother, but my loss was compounded by how complicated our relationship had been as she spiraled into alcoholism later in life. Her drunk version was mean, terrifying, and vicious, although when she was sober, she remained the loving, funny, if quirky, parent I knew as a child. When I moved to the United States, most of our conversations took place over the phone, and I became a human Breathalyzer via voice — a sad talent, I suspect, that I share with other children of alcoholics. Before she even finished saying “Hello,” I knew exactly how drunk she was, and if it was Jekyll-time, I just hung up without fanfare. It never went well if I didn’t.

Then my phone rang early one morning. I jumped out of bed to learn that she had died, without apparent reason — just dropped dead. My mind raced with only one thought: What was our last conversation? Had I hung up on her?

Losing an alcoholic parent can be marked by the same grief anyone feels after losing a parent, especially under tragic circumstances. But it’s also full of regret and guilt in its own ways. The regret is obvious: There is no longer a chance for a final, redemptive chapter. The guilt is layered: Was there anything else one could have done? One more intervention, despite the futility of all the others? And what to do with the feeling of relief from avoiding other, even more feared futures that tangles up with the loss?

In this knot of confusing feelings, though, it was that last conversation that my mind kept circling around for the next many months. The last time my mother called me, she was not only sober; she was in a reflective mood — something that did not happen a lot. She apologized, sort of, for all her drinking and said she was very proud of me. We had a pleasant, lengthy conversation, a rarity that year. She wanted to talk about the latest books she was thinking of translating. She rambled about all the good times, and came back to how happy she was that I was her daughter. It was as close to closure as one could hope for. Intellectually, I knew that it didn’t matter much and that even if I had hung up on her the last time — as I had so many times before — I could have tried to focus on some other good conversation or experience we had shared. I knew it was a stroke of luck that this just happened to be our final conversation. It’s not logical, but that’s how grief works; in the thick of it, the last conversation feels like the truest word.

It’s been six months since the world began battling COVID-19. Coronavirus cases are now surging across the Sun Belt, and hospitals are filling up again. Immediately, some reacted by restricting visitorsMany places had never lifted their restrictions in the first place. Those facing the worst moment of their life still aren’t being treated as a priority.

That dying alone has been normalized, as if it were a small matter, is frightening and inhuman. The panic of the early days of the crisis could be seen as a temporary, terrible compromise. Since then, though, airlines have been bailed out to the tune of many billions of dollars, while there has been no rush to build more negative-pressure rooms, designed to circulate air out, at hospitals, which would allow for much safer visits. We still haven’t developed the infection-control protocols for visitors and built up supplies of personal protective equipment in ways that would avoid the need to completely isolate patients in the days and months ahead.

Even without all the wisdom of the ages, it takes a special kind of inattention to human suffering to not notice how unfortunate this is, that people have been left to face death alone. Some have come to fear dying alone more than the coronavirus itself.

In the years after my mother’s death, I managed to move my focus away from the last conversation and take stock of the good and the bad. I regained perspective, and now I would be at peace with whatever had transpired the last time we spoke, even if I had indeed hung up on her. After a bit of time, I am able to broaden out and consider everything, not just that one last conversation. But that certainly wasn’t always the case. The adage is true: Time has its own healing powers. But that’s not what the people who have lost loved ones to this pandemic should be left with, that time will help with the injustice of having been separated from them at the very end. If society seems to have lost perspective about both compassion and death, all that may be left for us is to reclaim what perspective we can, as best we can.

Learning from Taiwan about responding to Covid-19 — and using electronic health records

outlier — and not in a good way — with more than 2.5 million cases and 125,000 deaths, or about 36 deaths per 100,000 people. One of the strongest performers is Taiwan, with 446 confirmed cases and just seven deaths for nearly 24 million citizens, or 0.03 deaths per 100,000. On a per capita basis, the U.S. has 1,200 times as many Covid-19 deaths as Taiwan.

Lost in the fractious and frankly broken conversation about reopening the economy is a simple truism: containing the virus is the best fiscal stimulus. The U.S. Congressional Budget Office is projecting double-digit contractions in the gross domestic product for 2020 and unemployment rates going up to 16% this year — the highest they have been since the Great Depression. By comparison, Taiwan’s central bank expects growth to slow to about 1.5% for the year, and unemployment has “surged” to 4.1%.

To get the economy moving again, we need a functioning health care system.

A lot can be learned about handling a pandemic — and its aftermath — by looking at the health care systems in other countries. Over the past few years, we have been studying 11 countries to write a book titled, “Which Country has the World’s Best Health Care?” Taiwan was one of the countries we studied, and its successful response to Covid-19 was not a matter of luck. It was the result of careful planning and digital innovation, which the U.S. must learn from.

Taiwan could easily have had a Covid-19 disaster. It is situated less than 100 miles from China, and more than 1 million Taiwanese work in China. There is frequent travel between the two countries. As a result, Taiwan is at high risk of exposure to any novel infection that arises in China. So why didn’t it get slammed by SARS-Cov-2?

Some of the success is due to accidents of history, including the outbreak of severe acute respiratory syndrome (SARS) that began in February 2003. It generated a culture of taking infections from China seriously — unlike what happened in the U.S. The island also has a strong “face mask” culture, which the U.S. should be emulating, but isn’t.

Perhaps the most important element is Taiwan’s deliberate, systematic use of its digital health infrastructure.

The key to avoiding massive, economically ruinous lockdowns is effective testing, isolation, and contact tracing to control viral spread. Taiwan’s innovative electronic health records system made possible the country’s swift, targeted response to Covid-19. Although the system was not designed to stop a pandemic, it was nimble enough to be reoriented toward one.

Every person in Taiwan has a health card with a unique ID that all doctors and hospitals use to access online medical records. Providers use the card to document care episodes for reimbursement from the Ministry of Health. As a result, the card gives the ministry regular, nearly real-time data on physician and hospital visits and use of specific services.

With that data, the ministry can modify payments to reflect utilization. If physicians collectively have more office visits than anticipated or are ordering more MRI scans than budgeted, payments per service are reduced quarterly to reflect the overuse. This payment-adjustment mechanism allows the country to adhere to its annual health care budget and return information to physicians on aggregate and individual resource utilization.

When Covid-19 hit, the health card and electronic health records system were repurposed to fight the spread of the virus.

The government merged the health card database with information from immigration and customs to send physicians alerts about patients at higher risk for having Covid-19 based on their travel history. Utilization data was also employed to identify candidates for Covid-19 testing when supplies were limited. As researchers reported in the Journal of the American Medical Association, “Taiwan enhanced Covid-19 case finding by proactively seeking out patients with severe respiratory symptoms (based on information from the National Health Insurance [NHI] database) who had tested negative for influenza and retested them for Covid-19.” The availability of almost immediate data on patient visits allowed the country to efficiently identify, test, trace, and isolate cases. This has dramatically reduced Covid-19 spread without the need for extensive lockdowns.

No other country we studied had a comparably effective real-time electronic health record system, including the U.S. The U.S. has come a long with its use of electronic records, thanks in part to the financial incentives built into the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. The percentage of office-based physicians who use these systems has grown from 48% in 2009 to 86% today. They are nearly universal in hospitals as well, with utilization now at 96%.

But sharing the data — so-called interoperability between different electronic health record vendors — has lagged. Only now are we beginning to see real-time data monitoring to permit proactive interventions to improve quality of care, not only in a pandemic but also in routine care. Only recently has the data been used to give physicians timely feedback on their quality of care and resource use. It will be years before these features become integral to routine health system operations across the entire country. As Taiwan shows, however, this is a challenge of policy, not technology.

Even in the midst of the ongoing pandemic, we can learn from Taiwan. Americans share every movement and sentiment with Facebook and Google, yet we seem reluctant to allow the Department of Health and Human Services to monitor patient encounters, as Taiwan does, to track disease and determine what medical tests and treatments to order.

Medicare and Medicaid could adopt something similar to the Taiwanese health card and allow an independent third party to monitor the data. The third party could proactively identify infectious outbreaks, deficiencies in the quality of care, and other important health issues. The contract would have to strictly forbid sharing the underlying data or commercializing them in any way.

Insurers already get data based on hospital and physician claims, but only weeks or months after encounters, making the information less useful for tracking infectious outbreaks. They could use Taiwan as a model to upgrade their data systems and share the insights with public health authorities.

Such an upgrade is tremendously expensive, prohibitively so without inducement. Fortunately, the HITECH Act showed that the federal government can spur investment in electronic health records. Nearly a decade since HITECH, we have the benefit of hindsight for what went well and what went wrong. Another round of investment in electronic health record upgrades — specifically targeted to generating interoperable data that can be shared in real time with public health officials — should be part of any new stimulus bill.

Taiwan’s amazing success in responding to Covid-19 highlights ways the U.S. can improve its pandemic response. By now it is evident that we need a faster, more serious response to public health emergencies, and Taiwan’s health card offers a basis for executing such a response.

Shoring up the U.S.’s digital health infrastructure will help improve routine care in the long run while empowering us to better respond to future infectious disease outbreaks.

Ezekiel J. Emanuel is a physician, vice provost of global initiatives, professor of medical ethics and health policy at the University of Pennsylvania. He is also the author of “Which Country Has the World’s Best Health Care?” (Public Affairs, June 2020), co-host of the “Making the Call” podcast, and a member of the Biden for President public health advisory committee. Cathy Zhang is a senior research fellow at the Department of Medical Ethics and Health Policy at the University of Pennsylvania. Aaron Glickman is a project manager in the Department of Medical Ethics and Health Policy at the University of Pennsylvania.

About the Authors:

Ezekiel J. Emanuel

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Cathy Zhang

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Aaron Glickman

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Researchers report nearly 300 cases of inflammatory syndrome tied to Covid-19 in kids

Two U.S. research groups have reported finding nearly 300 cases of an alarming apparent side effect of Covid-19 in children, a condition called multisystem inflammation syndrome, or MIS-C. While researchers have previously reported on the condition, the papers mark the first attempt to measure how frequently the side effect occurs and how it affects children who develop it.

The studies, published in the New England Journal of Medicine, describe children who develop severe inflammation affecting multiple organ systems after having had Covid-19, sometimes between two and four weeks after the infection. The majority of the children were previously healthy.

In one of the studies, led by researchers at Boston Children’s Hospital, 80% of the children who developed the condition required intensive care, 20% required mechanical ventilation, and four children, or 2%, died. In the second study, from researchers from New York state, a similar percentage of 99 children who developed the syndrome required ICU care and two children died. In both studies, many of the children developed cardiovascular and clotting problems and many had gastrointestinal symptoms. A high proportion also had skin rashes.

“Ours were really sick kids,” said Adrienne Randolph, an ICU physician at Boston Children’s Hospital and senior author on one of the papers, which was based on reports from 26 states.

How likely are kids to get Covid-19? Scientists see a ‘huge puzzle’ without easy answers

Manish Patel, from the Centers for Disease Control and Prevention’s Covid-19 response team, said the message to parents is they should be on the lookout for fever and rash in children who have recently had Covid-19.

“I think being a little vigilant is important,” said Patel, who is an author on Randolph’s paper. “Fever, rash and I think especially in the setting of areas where you have a lot of coronavirus infections, SARS-CoV-2 infections — have a lower threshold for seeking care, I would say.”

On the whole, children appear to contract SARS-CoV-2 less often than adults and have a milder course of disease when they do.

But in late April, doctors in London alerted the world to the possibility that some children who had Covid-19 appeared to go on to develop something that looked like Kawasaki’s disease, an inflammatory condition that can attack the heart. KD, as it is called, is generally seen in children under the age of 5. Shortly thereafter, doctors in New York began to report cases as well.

In mid-May, the CDC asked doctors across the country to be on the lookout for cases of multisystem inflammatory syndrome in children.

The nearly 300 cases identified in these two studies share some similarities with KD, but there are also differences. Few of the children are under the age of 5. The average age of children in the larger study was 8; 42% of the children in the New York cohort were aged 6 to 12.

Another difference: While KD disproportionately affects children of Asian descent, MIS-C cases in the New York cohort were of all racial and ethnic backgrounds, the researchers reported.

“Among our patients, predominantly from the New York Metropolitan Region, 40% were Black and 36% were Hispanic. This may be a reflection of the well-documented elevated incidence of SARS CoV-2 infection among black and Hispanic communities,” they wrote.

The New York group estimated that the majority of MIS-C cases occurred about one month after the peak of Covid-19 cases in the state. They estimated that between March 1 and May 10, two of every 100,000 people under the 21 years of age who had laboratory-confirmed SARS-CoV-2 virus developed MIS-C in the state. The infection rate in people under the age of 21 years was 322 in 100,000 over that period.Trending Now: 

An editorial written by Michael Levin, from the department of infectious diseases at Imperial College London, said there have been roughly 1,000 pediatric cases of the condition reported worldwide to date. He suggested more are likely going unrecorded, because case definitions require evidence of prior Covid-19 infection.

“There is concern that children meeting current diagnostic criteria for MIS-C are the ‘tip of the iceberg,’ and a bigger problem may be lurking below the waterline,” Levin wrote.

Unless it’s done carefully, the rise of telehealth could widen health disparities

The Covid-19 pandemic has pushed telehealth — the remote provision of health care resources, tools, and consultation, usually via digital technologies — from the backwaters of medicine to its leading edge.

Though novel to some health care providers, and considered impractical by others, telehealth will likely endure — and become even more appealing — after the Covid-19 pandemic has faded away. We are concerned that this crisis-driven acceleration in the adoption of virtual visits and use of algorithmic tools will have uncertain implications for the equitable distribution of health resources and will widen racial and class-based disparities in health.

The changes that have made possible the wider use of telehealth appear to be temporary. For instance, health insurers, who once declined to fully reimburse virtual visits to physicians, nurse practitioners, and other health providers, are now making exceptions expressly tied to the nature of the pandemic. Yet research and theory from the social sciences on institutional change would predict that there may not be a clear-cut return to “normal” once this crisis is over.

The adaptation to Covid-19 has realigned the power and positions of physicians, nurses, insurance companies, hospitals, and telehealth startups in providing health services to different communities. Providers are establishing new policies and automated systems around triage, virtual visits, and infection control that may become taken-for-granted work routines going forward. Such practices may be laying the foundation for opportunism in the expansion of telehealth markets above and beyond their value in treating disease and saving lives by allowing compensation for unnecessary visits.


Telehealth is a ‘silver lining’ of the pandemic, but implementing it permanently won’t be easy

For some time, technology companies have sought to disrupt the health sector with algorithms and other patient-centered digital innovations. These companies are now rushing to consolidate their positions before the opportunities presented by the pandemic abate.

Some providers and hospitals, attracted by potential reductions in cost and in potential improvements in patients’ health outcomes, were early adopters of virtual visits and other telehealth technologies. With the emergence of Covid-19, providers who had once been prudently looking for an evidence-based way to add value to their practices have been pushed into rapidly developing telehealth strategies to keep their practices afloat. Academic medical centers that had previously piloted telehealth as a strategy to expand their referrals or to decrease readmissions are now leveraging this infrastructure to more intentionally maintain contact with patients who have been seen in their outpatient offices.

There’s no question that the expansion of telehealth could be a force for good. These changes may save lives during this crisis by keeping patients out of health care settings where exposure to Covid-19 may be high. In the post-pandemic era, they could provide greater access and convenience for some patients. But they could also worsen health disparities down the road if not implemented carefully.

In its earliest days, one of telehealth’s missions was to ensure greater access to health care services by populations that otherwise would go without proper or timely care and consultation, such as those who are incarcerated or who live in rural areas. Now it is being used as a tool to supplant in-person visits and expand patient markets, partly in response to consumer demand for convenience and efficiency. This emphasis on expanding patient markets and responding to well-resourced consumers’ demand may put marginalized groups with poor health, no health insurance, or few digital resources at risk.

A market-driven, consumer-centered vision of telehealth could have negative implications for marginalized groups that already face discrimination during in-person medical encounters. Marginalized racial and ethnic minorities are more likely to report discrimination within health care settings, influencing their willingness to trust providers and seek medical attention early.

Discrimination and mistrust could be magnified in virtual doctor-patient encounters, in which patients may not feel they can fully communicate and providers may be less mindful of guarding against implicit bias based on attributes such as race, ethnicity, or educational status.

The potential for racism and class bias to be encoded into telehealth algorithms is also worrisome. Predictive tools are imperfect — although they may be able to predict average patterns across groups, they can neither fully account for the complexity of individuals nor incorporate subtle variables that may assist in the identification and treatment of disease. While doctors misuse of these algorithms is mitigated by clinical judgement and training, a patients’ uninformed use of such algorithms in lieu of seeking professional medical advice could be harmful. This is particularly true of patients who belong to social groups underrepresented in algorithmic data.

Hospitals, insurers, policymakers, and health care professionals must carefully consider how the telehealth policies and routines they implement might have durable — and potentially harmful — reverberations. Research into the costs and benefits of specific telehealth applications at the individual and population levels is essential.

Institutional policies created during this pandemic will have long-lasting consequences on health disparities. We must work to ensure they are net positive.

Matthew Clair is a sociologist and assistant professor of sociology at Stanford University. Brian W. Clair is an orthopedic surgeon at Lahey Hospital and Medical Center in Burlington, Mass. Walter K. Clair is a cardiologist, professor of medicine at Vanderbilt University Medical School, and executive medical director of the Vanderbilt Heart and Vascular Institute.