BY, PhD, MPH, , PhD, AND , MD
Uncertainties attendant to COVID-19 surrounding what to do and not to do, how to be safe and protect have been infused with distraction, confusion, and chaos on multiple fronts. Uncertainty is exacerbated by the high degree of uncertainty spawned by fragmentary and conflicting information.
The SARS-CoV-2 (COVID-19) novel coronavirus has become the defining public health event in this generation by threatening the health, peace of mind, and livelihood of people globally and infusing our lives with uncertainty. There are no clear treatments or vaccines, though that is now on the horizon testing is still severely limited, and the quality or reliability of testing equipment is questionable and variable. Iconic social and cultural events have been canceled or postponed indefinitely. Schools have reopened and then closed again. Until effective treatments, a validated vaccine, and anti-virals have been developed, the concept of physical (social) distancing and masking is likely to remain with us for many more months.
Many people magically avoid uncertainty via intellectual fainting. Imagine a car heading towards me such that I cannot avoid its path, and not wanting to experience injury or death, I merely faint. Examining difficult problems or issues may be avoided by intellectual fainting or acknowledging an issue and then avoiding dealing with it magically, as if it never happened. In the case of COVID-19, misinformation, miscalculation, spinning, ignorance, conspiracy theories, and denial have caused additional uncertainties undermining our confidence and resilience. Where science and data could drive choices, safeguards, and insight, we have been remiss.
In the absence of good and actionable information, we become little more than passive spectators thrust into a situation of enforced helplessness. In an ambiguous, ever-changing universe, unwanted fulfillment of waiting is negative and fatiguing, so one gives up. Uncertainty does not give license to wing it.
Pandemic fatigue is increasing dramatically. The pandemic has resulted in so many cases of anxiety, depression, and reports of suicide due to the stresses of the viral pandemic, unemployment, business closures, risk of death, and the continuing restrictions.
We as a nation, and more, as a global system based on the best scientific analytical data, manage and predict the future of health care in the “new abnormal” as well as in additional crises.
Confusion, mixed messages, and uncertainty abound:
- How much better is handwashing than hand sanitizers?
- How distanced should physical/social distancing be?
- How long does the virus survive on various surfaces?
- Can you get the virus more than once?
- Who are most at risk?
- Do we all need to wear masks?
Now that we know more, we have a sense of better control of our destinies and some reduction of uncertainties. The time is ripe for lack of empowerment due to disinformation, misinformation, unexamined opinions, and conspiracy theories. We must be vigilant and not be swayed by the unreliable and the unproven. This vigilance itself can be empowering.
There is immense frustration from masks, stay-at-home orders, and mandates foisted upon us for the greater good or ill purposes. Public health officials, political leaders, and businesses have been forced to manage this crisis by shutting down the economy in some cases repeatedly for all but essential services. The morbidity and mortality associated with COVID-19 are exacerbated by increasing uncertainty, millions filing for unemployment, and pandemic fatigue, hundreds of thousands of deaths and over 10 million cases. We are learning to work from home, rediscovering Zoom and conducting business online or not at all. Proper and regular handwashing, and disinfecting surfaces have been emphasized. Individuals are asked to avoid large gatherings, keep a safe distance (6+-feet) and wear masks to prevent the transmission to or from other people in the community. Those who have been exposed or positively diagnosed are asked to self-quarantine for no less than 14 days.
Other recent pandemics, including SARS, MERS, Ebola, Zika, West Nile, pandemic influenza, including Swine (H1N1) and Avian (Reperant & Osterhous, 2017), have had minimal impact on the day-to-day lives of most people. Even other contagious diseases such as malaria, HIV/AIDS, and other sexually transmitted diseases have resulted in safe practices but have not threatened the global economy. High-risk behaviors, from unsafe sex, lack of hygiene, or failure to wear masks, are done at one’s own peril, without the perceived threat that their unsafe practices could impact other people. Contact tracing has been difficult to perform or not taken as seriously as it should be.
Public health officials have rarely had such an influence on our day-to-day lives. Epidemiologists have played a vital role in understanding and monitoring the course of the disease. Public health educators are critical in communicating vital information such as how the disease is transmitted and how transmission can be prevented, as well as empowering people to adopt preventive measures for their health, and the health of the people around them. Lessons learned from the prevention of everything from heart disease and diabetes to HIV/AIDS can be applied to COVID-19 and, more importantly, lessons learned from COVID-19 can be applied to other preventable health conditions.
The lifeboat for many has been the use of technology to conduct their business and to stay connected to friends and family. Video conferencing and other forms of telemedicine have an inherent advantage in that they reduce exposure to the virus while allowing us to stay connected. While this has been an adjustment for many, these technologies are likely here to stay and will continue to allow many industries to function, including healthcare. Digital health solutions, including virtual visits with healthcare providers, remote monitoring of key biometrics such as blood pressure, glucose, O2 saturation, and weight, apps that provide access to information and communication with providers, and knowledge gained from other individuals who are experiencing the same condition will fundamentally change how healthcare is delivered in the future. Unfortunately, this can also be a barrier to those who do not have access to technology. These solutions can be a tool to facilitate the empowerment of individuals and their healthcare providers or create even further distance.
Immense energy is dedicated to guiding how to manage COVID-19 and reduce the incidence of the disease, morbidity, and mortality. Health care innovators are engaged in identifying or creating solutions to address a wide range of COVID-19-related issues. These involve vaccines, antivirals, testing, contact tracing, disinfecting, PPE transportation, and the like. There are some exciting solutions on the horizon. One unique solution comes from Seqster, which has created a platform that combines comprehensive medical records, individual genomic profiles, and personal health device data. Seqster can identify those who have already had COVID-19 by reviewing data from past lab tests from Quest Diagnostics and LabCorp. Anyone on the platform can share key health metrics related to COVID-19, such as body temperature, heart rate, and pulse oximetry, already synced with devices connected to their profile. Patients can now self-report on symptoms of COVID-19 like shortness of breath, fatigue, and coughing.
While, the genie is out of the bottle, we can still have immense impact on better managing, monitoring, and minimizing the risk and dangers of COVID-19. There is great promise on the horizon. NASA-inspired bio-acoustical sensor technology may be effective for identifying the virus asymptomatically, there are COVID-19 sniffing dogs in Finland, rapid testing, and thermal sensing to identify those with elevated temperatures and mask wearing at a distance of up to 4 meters. Also developed are dependable and accessible PPE, proven behavioral health strategies, medical coordination between home and school, telehealth, and remote monitoring. We are on the path to making a big difference. Many more innovations and solutions are on the near horizon, with more solutions to come.
Good, reliable, and accurate information is critical to offer guidance and reduce uncertainty and confusion. For decades, we have used knowledge and health literacy to prevent both infectious and chronic conditions. Our model for preventing and managing cardiovascular disease is relevant to COVID-19. The model starts with the building of knowledge and skills necessary to prevent or manage the condition. COVID-19 is an example of the need to build knowledge so that people understand the threat that the pandemic represents to them and their families. Numeracy skills are needed to understand disease transmission, i.e., 6 feet, how long the virus lives in different environments, and the concept of flattening the curve. Navigational skills are necessary to inform people about when and where to be tested, and when to access the healthcare setting. Communication skills are critical to sharing information on symptoms and clarifying treatments. Finally, decision-making skills are needed for self-isolation, quarantine, and return to work. The key factor that makes this model work is the empowerment of the individual.
Our model for empowering individuals to build their health literacy is to:
(1) Address the emotional and mental health of the individual.
(2) Develop a behavioral strategy that will engage and motivate the person to take positive action.
(3) Provide them with the knowledge and skills they need to be successful.
Attention to key mental health factors such as mindfulness, emotional resilience, physical distancing, and social interaction will be necessary to build these skills. Once these skills are developed, however, the benefits to infections, chronic disease, individuals, and groups may be profound and more effective than our pre-COVID-19 environment.
The stakes have never been more profound or the opportunity so great since the influenza pandemic of 1918. If we are not vigilant, we will mirror or exceed the devastation of the Spanish flu. That pandemic led to basic science breakthroughs in the understanding of the influenza virus, and the importance of disease surveillance public trust and public health communication. As is the case today, communities that followed recommendations of public health leaders had much less loss of life than those communities that ignored the recommendations. While COVID-19 is a global disaster on many levels, our connected world and a better understanding of mental health, empowerment, and prevention will lead to new opportunities to make the world a healthier and happier place to live.
NEXT STEPS: HOW DO WE PLAN THE FUTURE OF HEALTHCARE?
The best way to plan for the future is to create a strategic plan, which usually involves the use of scenario analysis looking at all possibilities to plan our actions, possibilities opportunities, and how to avoid errors as we look for what we teach our students, “process improvement.”
But we can’t improve anything, strategically plan, or analyze the possible scenarios unless we have the data to analyze this virus, the multiple tests, the medications used for treatment, the medications in development, vaccines, antivirals, anti-inflammatories, and immunosuppression or immunomodulating drugs, etc.
In his article, Nine Tips to Manage Reentry After the Pandemic, featured in the Forbes Council Post, Mark Samuel1 wrote that scenario planning allows us to come up with 3-5 possible scenarios and shift direction as the facts, and I stress facts, and future crystallizes and we’re able to find some footing. In this type of analysis, we need to think about the most probable types of challenges that could occur and proceed, using cross-functional input and all relevant data.
Samuel’s tip number 7, which states, “you can’t know if you’re on the right track if you’re not tracking your results and your habits,” Is particularly interesting. You need to “come up with metrics that not only indicate the outcomes you are achieving, but also the effectiveness of the new habits you have implemented to accelerate performance and improve effectiveness.”1 This will inform and assist you in your decisions to move to a different scenario plan or implement a proactive recovery plan.
Taxing times require innovative solutions. Almost daily we see authorities announcing their predictions about the virus, how long the virus is infectious, contact surface considerations, antibodies, immunity, herd immunity, who is most in jeopardy, the relationship of comorbidities, and age. All these predictions were and are based on models, but as the British statistician George E.P. Box once stated “All models are wrong, but some are useful.”2 More importantly, models are better for making predictions when we have the best data with the most appropriate sample size.
Of more than 100 labs across the world working toward a vaccine against the deadly virus, 10 are in the clinical-trial stage. Many big companies have joined forces to develop a vaccine. However, the World Health Organization has said that to increase chances of success, it is “critical to test all candidate vaccines until they fail.”3 And how do we assess success or failure, but with the collection of data, analysis, and prediction models.
We need to be indefatigable and relentless in our search for the treatment and the ultimate goals – eradicating COVID-19 and the development of the needed vaccine. Most viruses mutate, as reported by Italian physicians recently, and so this continual study, analysis, and integration of data will allow our healthcare providers to adjust to these mutations of the viruses and manage each crisis.
In respect to vaccines, we will need a phased approach to vaccination. We will need to Identify and estimate critical populations, assess current vaccine administration capabilities, create methodologies for prioritizing distribution, address storage challenges as well as address barriers for underserved communities and vaccine stigma and confidence issues.
Most important, government leaders can help ensure that hospitals get the vital resources they need to treat patients, protect doctors and nurses, and support the research in the development of vaccines to defend us from this virus. They can also work with the private sector to ensure that testing is readily available, something that has to date hampered efforts to contain the coronavirus in United States. Some experts believe the best economic medicine that the public sector can provide is a quick resolution to the underlying health threat. As we are promoting in this paper, we need to have a high level of software intelligence to accumulate the data that will allow us to evaluate the success or failure of the long-term use of antivirals and vaccines and to have models to predict the additional crises.
Even before the pandemic, we were struggling on so many fronts, and now it is much worse. The good news is, things don’t have to be this way. We have the power to make it better by doing something bold and effective. In February 2021, we plan to launch a multi-pronged back-to-school program integrating behavioral health, social determinants, AI-driven smart surveillance technologies, Emmy award-winning animation content to promote and sustain heath behaviors, PPE, and medical coordination to support school nurses while monitoring temperature remotely to ensure safety at home and at school daily, to minimize exposure and spread. There is indeed hope for a safer and more promising future.
Toward a National Conversation on Health: Disruptive Intervention and the Transformation from Health Care to Health. Kevin A Dorrance, USN (Ret); Dennis A Robbins; Linda Kimsey, USN (Ret); Jeffrey S LaRochelle, USAF (Ret); Steven Durning. Military Medicine, Volume 183, Issue suppl_3, 1 November 2018, Pages 193–197, https://doi.org/10.1093/milmed/usy215
Promoting and Sustaining Positive Personal Health Behaviors – Putting the Person First. Deydre S Teyhen, USA; Dennis Robbins; Barbara Agen Ryan, USA (Ret). Military Medicine, Volume 183, Issue suppl_3, 1 November 2018, Pages 213–219, https://doi.org/10.1093/milmed/usy212
Ethical Dimensions of Clinical Medicine edited by Dennis a Robbins and Dyer, A Springfield Illinois: Charles Thomas Publishers, chapter 3, Uncertainty an unresolved problem and clinical medicine and ethics pp 32-41.
AHA Primary Prevention guidelines. Robbins-Dunn – Digital health literacy in a person centric world
Reperant, LA, Osterhaus, A. AIDS, Avian flu, SARS, MERS, Ebola, Zika… what next? Vaccine. 2017: 35;4470-4474. https://www.sciencedirect.com/science/article/pii/S0264410X17305832?via%3Dihub